Monica B.

Lemos
Ekene Okoye
Editors

Atlas of
Surgical Pathology
Grossing

123
Atlas of Anatomic Pathology
Series Editor
Liang Cheng
Indianapolis, Indiana, USA
This Atlas series is intended as a “first knowledge base” in the quest for diagnosis of usual and
unusual diseases. Each atlas will offer the reader a quick reference guide for diagnosis and
classification of a wide spectrum of benign, congenital, inflammatory, nonneoplastic, and
neoplastic lesions in various organ systems. Normal and variations of “normal” histology will
also be illustrated. Each atlas will focus on visual diagnostic criteria and differential diagnosis.
It will be organized to provide quick access to images of lesions in specific organs or sites. Each
atlas will adapt the well-known and widely accepted terminology, nomenclature, classification
schemes, and staging algorithms. Each volume in this series will be authored by nationally and
internationally recognized pathologists. Each volume will follow the same organizational
structure. The first Section will include normal histology and normal variations. The second
Section will cover congenital defects and malformations. The third Section will cover benign
and inflammatory lesions. The fourth Section will cover benign tumors and benign mimickers
of cancer. The last Section will cover malignant neoplasms. Special emphasis will be placed on
normal histology, gross anatomy, and gross lesion appearances since these are generally lacking
or inadequately illustrated in current textbooks. The detailed figure legends will concisely
summarize the critical information and visual diagnostic criteria that the pathologist must
recognize, understand, and accurately interpret to arrive at a correct diagnosis. This book series
is intended chiefly for use by pathologists in training and practicing surgical pathologists in
their daily practice. The atlas series will also be a useful resource for medical students,
cytotechnologists, pathologist assistants, and other medical professionals with special interest
in anatomic pathology. Trainees, students, and readers at all levels of expertise will learn,
understand, and gain insights into the complexities of disease processes through this
comprehensive resource. Macroscopic and histological images are aesthetically pleasing in
many ways. This new series will serve as a virtual pathology museum for the edification of our
readers.

More information about this series at http://www.springer.com/series/10144

Monica B. Lemos  •  Ekene Okoye
Editors

Atlas of Surgical Pathology

Grossing
Editors
Monica B. Lemos Ekene Okoye
Houston Methodist Hospital Houston Methodist Hospital
Houston, TX Houston, TX
USA USA

ISSN 2625-3372     ISSN 2625-3380 (electronic)

Atlas of Anatomic Pathology
ISBN 978-3-030-20838-7    ISBN 978-3-030-20839-4 (eBook)
https://doi.org/10.1007/978-3-030-20839-4

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
My special thank you to my son, Jaymesson Bezerra,
for being with me in my moments of fear and
frustration, for always showing me the light at
the end of the tunnel.
 Monica B. Lemos

To my beloved family – Chike, Chiamaka, Nkechi, and

Oluchi – for their love and support. To my amazing
mentors and colleagues in pathology, and to all the
wonderful residents and fellows I have had the
fortune of working with.
 Ekene Okoye
Series Preface

One Picture Is Worth Ten Thousand Words

— Frederick Barnard, 1927

Remarkable progress has been made in anatomic and surgical pathology during the last
10 years. The ability of surgical pathologists to reach a definite diagnosis is now enhanced by
immunohistochemical and molecular techniques. Many new clinically important histopatho-
logic entities and variants have been described using these techniques. Established diagnostic
entities are more fully defined for virtually every organ system. The emergence of personalized
medicine has also created a paradigm shift in surgical pathology. Both promptness and preci-
sion are required of modern pathologists. Newer diagnostic tests in anatomic pathology, how-
ever, cannot benefit the patient unless the pathologist recognizes the lesion and requests the
necessary special studies. An up-to-date Atlas encompassing the full spectrum of benign and
malignant lesions, their variants, and evidence-based diagnostic criteria for each organ system
is needed. This Atlas is not intended as a comprehensive source of detailed clinical information
concerning the entities shown. Clinical and therapeutic guidelines are served admirably by a
large number of excellent textbooks. This Atlas, however, is intended as a “first knowledge
base” in the quest for definitive and efficient diagnosis of both usual and unusual diseases.
The Atlas of Anatomic Pathology is presented to the reader as a quick reference guide for
diagnosis and classification of benign, congenital, inflammatory, nonneoplastic, and neoplastic
lesions organized by organ systems. Normal and variations of “normal” histology are illus-
trated for each organ. The Atlas focuses on visual diagnostic criteria and differential diagnosis.
The organization is intended to provide quick access to images and confirmatory tests for each
specific organ or site. The Atlas adopts the well-known and widely accepted terminology,
nomenclature, classification schemes, and staging algorithms.
This book series is intended chiefly for use by pathologists in training and practicing surgi-
cal pathologists in their daily practice. It is also a useful resource for medical students, cyto-
technologists, pathologist assistants, and other medical professionals with special interest in
anatomic pathology. We hope that our trainees, students, and readers at all levels of expertise
will learn, understand, and gain insight into the pathophysiology of disease processes through
this comprehensive resource. Macroscopic and histological images are aesthetically pleasing
in many ways. We hope that the new series will serve as a virtual pathology museum for the
edification of our readers.

Indianapolis, IN, USA Liang Cheng, MD

vii
Preface

The idea for this book came from Dr. Alberto Ayala, my mentor. He called me into his office
and said “Monica, you should write a grossing manual.” Immediately my answer was “I don’t
know how to do that!” He said very calmly, “Just put on paper everything that you have been
teaching the residents.” At first, I freaked out; I did not want to disappoint him. But then I
started to think about it, and the first idea that came to my mind was the image of a specimen
with a white background, giving the resident, PA, or fellow that would open this book the
impression that the specimen was right there in front of them. The second idea was that it
should be predominantly pictures, following a step-by-step approach, trying to lessen the fear
of a person who is just beginning to gross specimens, and also lessen doubts they might have
about more complex specimens. The idea is to gross in a simple and efficient way. Knowing
how to gross thoroughly and efficiently is incredibly important.
The focus of this Atlas is intentionally on the images of actual gross specimens, as opposed
to solely illustrations of gross specimens. The images highlight key features of various types
of gross specimens. The use of actual gross images will allow the reader to more readily apply
the grossing tips to actual specimens that they encounter at the grossing bench. This book
contains many grossing tips, as well as sample dictations, that complement and complete the
visual grossing lessons this book provides.
The goal of this book is to help pathology trainees (residents, fellows, pathology assistant
students) learn how to gross a variety of specimens, and to give more experienced practitio-
ner’s additional ideas for how to gross in the most efficient manner. Thus in addition to pathol-
ogy trainees, we hope that attending pathologists and practicing pathologist assistants may
also benefit from this book.
Finally, always think about how you would like a case to be grossed as if the patient were a
member of your own family. With that thought in mind, you will always perform a gross
examination with care and efficiency.

Houston, TX, USA Monica B. Lemos

Ekene Okoye

ix
Acknowledgments

Teaching residents has become my heart. Working as a PA in Houston Methodist Hospital and
also continuing part time at MD Anderson is for me the basis of my accomplishments. Along
the path I met people who gave me so much knowledge and support for everything that I have
achieved as a PA. Thank you to all the residents and fellows along these 4 years (2012–2016):
Drs. Sergio Pina, Miguelina De La Garza, Daniel Wimmer, Jana Wimmer, Nicole Nelles,
Suzanne Crumley, Natasha Golardi, Andreia Barbieri, Ziad El-Zaatari, and Ahmed Shehabeldin.
To the Department of Pathology and Genomic Medicine at Houston Methodist Hospital for all
the amazing support from the attendings: Drs. Alberto Ayala, Dina Mody, Steven Shen, Patricia
Chevez Barrios, April Ewton, Ekene Okoye, Blythe Gorman, Mary Schwartz, Donna Coffey
(for her unconditional friendship and support), Michael Deavers, Roberto Barrios, and Mukul
Divatia (for his vast knowledge and for always going completely out of his way to help me).
Also, thank you to the attendings from MD Anderson who became part of my life: Drs. Aysegul
Sahin, Nour Sneige, Patricia Troncoso, Elvio Silva, Victor Prieto, Fraser Symmans, and Stanley
Hamilton. I also thank Dr. Michelle Williams for her guidance. And especially to the person
who started my history in this country, Dr. Janet Brunner.
Many thanks to Dr. Ziad El-Zaatari for his great assistance and work on the digital image
editing for this book. We greatly thank Dr. Sasha Pejerrey for her assistance.
I especially want to thank Dr. Alberto Ayala. This book is your idea, the seed that you
planted with love and care. The only thing I want is for you to be proud. Thank you for believ-
ing in me, for pushing me through my fears, and for holding my hand through my career. You
are a real teacher, a teacher and mentor of us all, the example of character, knowledge, patient
care, love, and dedication. As a daughter to a father, I want to say with all my heart: Thank you,
Dr. Ayala.
Monica B. Lemos

xi
Contents

1 Skin���������������������������������������������������������������������������������������������������������������������������������   1
Monica B. Lemos and Patricia Chevez-Barrios
2 Breast�����������������������������������������������������������������������������������������������������������������������������   5
Monica B. Lemos and Nour Sneige
3 Head and Neck �������������������������������������������������������������������������������������������������������������  13
Monica B. Lemos and Alberto Ayala
4 Gastrointestinal Tract���������������������������������������������������������������������������������������������������  27
Monica B. Lemos and Mary Schwartz
5 Hepatobiliary and Pancreas�����������������������������������������������������������������������������������������  43
Monica B. Lemos and Mary Schwartz
6 Genitourinary���������������������������������������������������������������������������������������������������������������  55
Monica B. Lemos and Steven Shen
7 Female Reproductive Tract �����������������������������������������������������������������������������������������  67
Monica B. Lemos, Donna Coffey, and Michael Deavers
8 Lung�������������������������������������������������������������������������������������������������������������������������������  83
Monica B. Lemos and Roberto Barrios
9 Bone and Soft Tissue�����������������������������������������������������������������������������������������������������  89
Monica B. Lemos and Michael Deavers
Index�������������������������������������������������������������������������������������������������������������������������������������  95

xiii
Contributors

Alberto Ayala, MD  Department of Pathology and Genomic Medicine, Houston Methodist

Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
Roberto Barrios, MD  Department of Pathology and Genomic Medicine, Houston Methodist
Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
Patricia  Chevez-Barrios, MD  Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
Donna  Coffey, MD  Department of Pathology and Genomic Medicine, Houston Methodist
Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
Michael Deavers, MD  Department of Pathology and Genomic Medicine, Houston Methodist
Hospital, Houston, TX, USA
Ziad El-Zaatari, MD  Department of Pathology and Genomic Medicine, Houston Methodist
Hospital, Houston, TX, USA
Monica B. Lemos, MD  Department of Pathology and Genomic Medicine, Houston Methodist
Hospital, Houston, TX, USA
Mary Schwartz, MD  Department of Pathology and Genomic Medicine, Houston Methodist
Hospital, Houston, TX, USA
Steven Shen, MD, PhD  Department of Pathology and Genomic Medicine, Houston Methodist
Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
Nour  Sneige, MD Department of Pathology and Genomic Medicine, Houston Methodist
Hospital, Houston, TX, USA

xv
 Skin
Monica B. Lemos and Patricia Chevez-Barrios
Dermatologic specimens, including skin biopsies and skin
excisions, are commonly encountered in the surgical pathol-
ogy grossing suite. This chapter focuses on skin excisions
and provides instruction on how to properly handle such
specimens.
Skin Excision
Skin excisions are performed primarily for complete removal
of a lesion and to ensure accurate diagnosis of the lesion in
question. Skin excisions are often in the shape of a circle or
ellipse, but they can have irregular or non-symmetrical
shapes. (For specimens with complex shapes, a picture or
diagram made before sectioning can be a useful tool).
Margins include all of the soft tissue that was cut by the sur-
geon deep to the skin surface.
Orientation is often indicated by the surgeon with
sutures. It is frequently designated in terms of clock posi-
tions (1 o’clock to 12 o’clock all around). Typically, 12
o’clock is at the superior-most portion, 3 o’clock and 9
o’clock are at the medial and lateral positions, and 6 o’clock
is at the inferior-­most portion (Figs.  1.1, 1.2 and 1.3).
Inking is performed in such a way that this orientation can
be reconstructed while examining the specimen microscop-
ically, so that if microscopic lesions are detected close to or
involving a specific margin, the location of the positive
margin can be accurately conveyed to the surgeon, in order
M. B. Lemos (*)
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
e-mail: MBLemos@houstonmethodist.org
P. Chevez-Barrios
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
© Springer Nature Switzerland AG 2019
M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_1
1
to aid in a more localized and precise re-excision, if neces-
sary (Figs. 1.4, 1.5 and 1.6).
In addition to proper orientation, accurate measurement
of the size of the lesion and the distance from the lesion to
the peripheral and deep margins is essential.
Sample Dictation: Skin Excision
Received fresh/in formalin and labeled as “_____” is a tan-­
white/brown, oriented/unoriented, irregular/oval/circular/
elliptical skin excision (____ × ____ × ____ cm).
The surface of the skin shows a ____  cm ulcer/healed
scar/macule/papule/nodule or multiple pigmented lesion(s)
(____ to ____ cm), that is/are centrally/peripherally located,
abutting the peripheral edges/deep margin in the superior/
inferior aspect of the specimen.
The specimen is serially sectioned from lateral to medial
and the cut surface is yellow-tan/tan-white and unremarkable
(or) includes a tan-white/black lesion (____  cm) present
____ cm from the superior margin, ____ cm from the infe-
rior margin, and ____ cm from the deep margin.
The specimen is submitted sequentially from lateral to
medial into cassettes A1–A12 in its entirety.
Ink code:
• Superior – Blue
• Inferior – Orange
1
2 M. B. Lemos and P. Chevez-Barrios

Fig. 1.1  Skin excision:

orientation. The excision
specimen is oriented with a
long stitch placed by the
surgeon at 12 o’clock and a
short stitch at 9 o’clock. An
ulcerated lesion can be clearly
seen at the center, with a
surrounding area of normal
skin extending to the margins
circumferentially

Fig. 1.2  Skin ellipse. A skin

excision in the shape of an
ellipse. This specimen is
oriented and grossed in the
same manner as a circular
skin excision (see Fig. 1.1),
with the additional step of
submitting the tips of the
ellipse separately
1 Skin 3

Fig. 1.3  Skin excision with

scarred and pigmented
lesions. Lesions on the
surface of skin excisions can
have varied appearances. In
addition to pigmented lesions,
this specimen includes a
depressed area representing
the possible site of a scar

Fig. 1.4  Skin excision:

inking. The right and left
halves of the skin excision
specimen are inked with
separate colors. In this
picture, the specimen is
oriented with the skin surface
facing down. The margins on
any skin excision specimen
include all the surfaces of the
soft tissue deep to the
superficial skin surface
4 M. B. Lemos and P. Chevez-Barrios

Fig. 1.5  Skin excision: Sectioning. Sections are taken here sequen- medial. Sections can be bisected to fit into individual cassettes. Sutures
tially from 9 o’clock to 3 o’clock, perpendicular to the inked superior should be removed before submitting sections in cassettes. The tips or
and inferior halves. Sections are submitted sequentially from lateral to peripheral-most sections should be placed ink side up in the cassette

Fig. 1.6  Irregular skin excision. This irregularly shaped skin excision margins were inked differentially, and the specimen was serially sec-
was oriented by the surgeon’s sutures with a short suture on the superior tioned from lateral to medial, perpendicular to the superior/inferior
aspect and a long suture on the medial aspect. The superior and inferior halves

Suggested Reading Smith-Zagone MJ, Schwartz MR.  Frozen section of skin specimens.
Arch Pathol Lab Med. 2005;129:1536–43.
Weinstein MC, Brodell RT, Bordeaux J, Honda K. The art and science of
Bell WC, Young ES, Billings PE, Grizzle WE. The efficient operation of the
surgical margins for the dermatopathologist. Am J Dermatopathol.
surgical pathology gross room. Biotech Histochem. 2008;83:71–82.
2012;34:737–45.
Ghauri RR, Gunter AA, Weber RA. Frozen section analysis in the man-
agement of skin cancers. Ann Plast Surg. 1999;43:156–60.
 Breast
Monica B. Lemos and Nour Sneige
Breast cancer, one of the most commonly diagnosed cancers,
accounts for 30% of all new cancer diagnoses in women.
Therefore, breast specimens, including breast biopsies,
lumpectomies, and mastectomies, are commonly encoun-
tered in the surgical pathology grossing suite. This chapter
examines the proper handling of mastectomy and lumpec-
tomy specimens, as well as sentinel lymph nodes.
There are multiple types of mastectomy procedures. A
total simple mastectomy removes the whole breast and most
of the overlying skin, including the nipple. A modified radi-
cal mastectomy is similar to a simple mastectomy, but
includes an axillary dissection. A radical mastectomy
includes removal of the whole breast, overlying skin and
nipple, pectoralis muscles, and axillary lymph nodes.
(Though previously widespread, radical mastectomies now
are rarely performed.) More modern mastectomy methods
include skin-sparing mastectomies, which removes the
breast tissue, nipple, and areola only, as well as nipple-­
sparing mastectomies, which removes the breast tissue with-
out removing the overlying skin or nipple.
Lumpectomy procedures remove a portion of the breast
and are performed for removal of both palpable and non-­
palpable breast lesions. Breast-conserving therapy is becom-
ing more common, as many women with breast cancer are
candidates for this therapy, which includes a partial breast
excision (i.e., lumpectomy), usually with subsequent radia-
tion therapy. Survival outcomes are similar between patients
undergoing breast-conserving therapy with radiation therapy
versus patients who have a mastectomy.
Axillary lymph node sampling, most commonly in the
form of sentinel lymph node biopsy, is a standard staging
modality. Instruction on how to handle these specimens is
also included in this chapter.
M. B. Lemos (*) · N. Sneige
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
e-mail: MBLemos@houstonmethodist.org
© Springer Nature Switzerland AG 2019
M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_2
2
Mastectomy
Mastectomy is performed for malignant lesions of the breast
that are not amenable to localized excisions (see
Lumpectomy), or on an elective basis for other indications.
At our institution, margins of mastectomy specimens with
tumors, are grossly assessed during intraoperative consulta-
tion, making careful attention and quick mastery of orienta-
tion and grossing techniques essential.
Grossing Tips: Mastectomy
• When the specimen is received, first note the laterality
(right or left) and orientation of the mastectomy specimen
(e.g., short stitch, superior; long stitch, lateral).
• Imagine the patient in front of the prosector in order to see
the correct orientation. For example, lateral will be on the
left-hand side for a right breast and on the right-hand side
for a left breast (with superior being up in both examples)
(Fig. 2.1).
• Once the correct orientation is certain, ink the superior
and inferior halves of the specimen, each a different color
(Fig. 2.2).
• Next, flip the breast so that the deep surface now faces the
prosector and superior is still upwards.
• The deep surface of the specimen can now be inked. This
surface is usually flatter than its surroundings.
• With the breast still flipped, section the breast from lateral
to medial (right breast) or medial to lateral (left breast)
(Fig. 2.3).
• Lay out the slices as they are cut from lateral to medial
(right breast), or medial to lateral (left breast), keeping
track of the orientation of the slices.
• Number the slices (Fig. 2.4).
• Grossly locate any tumor(s) and measure the closest dis-
tance to each of the margins.
5
6 M. B. Lemos and N. Sneige
Fig. 2.1  Right mastectomy: Orientation. The mastectomy specimen
consists of four quadrants in addition to superior, inferior, medial, and
lateral sides. The specimen pictured also includes an axillary tail. The
orientation can be described by clock positions, with 12 o’clock superi-
orly, 3 o’clock medially, 6 o’clock inferiorly, and 9 o’clock laterally.
Note that the 3 o’clock and 9 o’clock positions would be switched with
Fig. 2.2  Mastectomy: Inking of margins. Three margins should be
inked on a mastectomy specimen: superior, inferior, and deep. The
superior and inferior halves are inked different colors. The specimen
respect to the medial and lateral sides in a left mastectomy specimen.
The nipple (or the base of nipple excision in nipple-sparing mastecto-
mies) is considered the center point around which the four quadrants
are arranged. This orientation scheme is used to describe the position of
masses or other breast lesions
should then be flipped and the deep surface inked. (Black, shown here,
is a common choice.) In a nipple-sparing mastectomy, the nipple area
should also be inked
2 Breast 7

Fig. 2.3  Sectioning a

mastectomy. The mastectomy
specimen should be sliced
along the long axis (medial to
lateral, or lateral to medial),
with the deep aspect always
facing the prosector. The
slices should be made as thin
as possible so that lesions on
the cut surface can be
effectively detected. To cut
effectively and keep track of
orientation, always slice the
breast with the skin
(superficial aspect) facing
down on the cutting board and
the superior aspect directed
upwards

Fig. 2.4  Mastectomy slices. Thinly sliced sections are laid out from lateral to medial and numbered sequentially. Now, the cut surface can be
examined for the presence of lesions and their proximity with respect to the inked margins
8 M. B. Lemos and N. Sneige
• Take sections sequentially according to the slice numbers
and document the slice number from which each section
was taken in the dictation (Note: Sequential sectioning
can help determine tumor size when tumors are detected
microscopically.)
• In some cases, it can be very helpful to make a diagram of
where sections were taken, so when viewing slides micro-
scopically it can be precisely known where in the breast
the section is from. This is also known as “mapping” of
breast sections (Fig. 2.5).
• The nipple, if included, should be submitted. Transect the
nipple and base of the nipple from the breast. Then tran-
sect the base of the nipple from the everted portion of the
nipple (after transecting, the base will have a circular, disc
like shape). Then serially section the remainder of the
nipple (everted part of the nipple). Submit the base of the
nipple and the serial sections of everted portion nipple in
two separate cassettes.
• For axillary dissections, a minimum of ten lymph nodes
should be found.
Sample Dictation: Mastectomy
Received fresh labeled as “right/left mastectomy” is an ori-
ented right/left mastectomy specimen (_____ grams,
Fig. 2.5  Mapping a mastectomy. Breast slices can be mapped to show
the locations of submitted sections. A photocopy of the breast slices is
taken by placing the slices between two clear plastic sheets; then the
_____  ×  _____  ×  _____  cm). Attached to the specimen
there is a _____  ×  _____  cm tan white/brown ellipse of
skin. The nipple and areola complex are grossly unremark-
able (or the nipple is inverted). The nipple is _____ cm in
diameter.
The breast is serially sectioned sequentially from
medial to lateral (left breast)/lateral to medial (right breast)
into _____ slices. The nipple is located in slice number
_____. The cut surface reveals on slice numbers _____,
_____, and _____ in the (UOQ/LOQ/UIQ/LIQ/UC/LC)∗∗
a tan/white irregular firm mass with areas of fat necrosis.
There is a surgical clip (shape, location/slice number) that
has been removed. The lesion is _____ cm from the supe-
rior margin, _____ cm from the inferior margin, _____ cm
from the deep margin, and _____ cm from the skin. The
remainder of the parenchyma is fibrous-fatty tissue
(_____% fibrous, _____% fatty) with multiple cysts rang-
ing from 0.2 to 0.4  cm and filled with tan brown dense
fluid.
Ink code:
• Superior – Blue
• Inferior – Orange
• Deep – Black
photocopy is annotated with the location of each section submitted, as
well as inked resection margins. (In this image, blue = superior, black =
deep, and orange = inferior.)
2 Breast
Section code:
Slice 8
• A1 – Junction of lower and upper aspect- central breast
• A2–A4 – Upper central
Slice 9
• A5–A7 – Upper outer quadrant (UOQ)
• A8 – Lower outer quadrant (LOQ)
Slice 10
• A9 – Upper outer quadrant (UOQ)
• A10 – Upper outer quadrant (UOQ); area with clip
• A11 – Lower outer quadrant (LOQ)
Slice 11
• A12–15 – Upper outer quadrant (UOQ)
• A16 – Junction of lower and upper aspect- outer breast
Slice12
• A17–20 – Upper outer quadrant (UOQ)
Etc.
∗∗UOQ – upper outer quadrant; UIQ – upper inner quad-
rant; LOQ – lower outer quadrant; LIQ – lower inner quad-
rant; UC – upper central; LC – lower central
Lumpectomy
A lumpectomy consists of removal of only a portion of the
breast. In many cases, the margins of resection in these speci-
mens are assessed during intraoperative consultation, simi-
larly to mastectomy specimens. The gross examination of
lumpectomy specimens is similar to that of mastectomy speci-
mens, however there are important differences as noted below.
Fig. 2.6  Lumpectomy with localization wire. A needle localization
wire is protruding from the surface of this oriented lumpectomy speci-
men. At our institution, lumpectomies are first placed in a Faxitron
9
Grossing Tips: Lumpectomy
• When the specimen is received, first note the laterality
(right or left) and orientation of the lumpectomy specimen
(e.g., short stitch, superior; long stitch, lateral) (Fig. 2.6).
• Once the correct orientation is certain, ink the superior,
inferior, superficial, medial, lateral and deep aspects each
a different color (Fig. 2.7).
• Section the breast lateral to medial (right breast) or medial
to lateral (left breast) (Fig. 2.8).
• Lay out the slices as they are cut from lateral to medial
(right breast) or medial to lateral (left breast), keeping
track of the orientation of the slices.
• Number the slices.
• Grossly locate any tumor(s) and measure the closest dis-
tance to each of the margins.
• At our institution, in most cases, lumpectomy specimens
are submitted entirely. The specimen can be submitted
sequentially according to the slice number. Document the
slice the sections are taken from.
• Just as in mastectomy specimens, mapping out where sec-
tions are taken from in a lumpectomy specimen can be
extremely helpful (Fig. 2.9). See Sect. 2.1.1 above.
Sample Dictation: Lumpectomy
Received fresh labeled as “____” is an oriented (_____
grams, _____ × _____ × _____ cm), right/left lumpectomy
specimen. A needle localization wire is present within the
specimen, and the specimen is submitted for Faxitron
imaging.
machine (Hologic; Marlborough, MA) before sectioning to confirm
radiographically the presence of a tumor localization clip. The actual
tumor, as well as calcifications, can also be seen on the x-ray images
10 M. B. Lemos and N. Sneige

Fig. 2.7 Lumpectomy:
Inking. There are six margins,
corresponding to the six faces
of a cube: superior, inferior,
medial, lateral, superficial,
and deep. Each margin is
inked in a different color

Fig. 2.8  Lumpectomy: Sections, clip localization, and margin assess- be found and removed before submitting sections. (This also applies to
ment. Thin slices are made from lateral to medial and are numbered clips in mastectomies.) The closest distance of the tumor to each of the
(top). The localization clip placed in a lumpectomy (bottom left) should lumpectomy margins (bottom right) should be measured and recorded
2 Breast 11

Fig. 2.9  Mapping lumpectomy sections. One can use the scheme in this image to submit the sections for a lumpectomy

The specimen is serially sectioned from lateral to medial
(right lumpectomy), or medial to lateral (left lumpectomy)
into ____ slices. The cut surface reveals in slice numbers
____, ____, and ____, a ____  ×  ____  ×  ____  cm mass
[describe the mass here]. The mass is associated with a surgi-
cal clip in slice ____. The mass is ____ cm from the superior
margin, ____ cm from the superficial margin, ____ cm from
the inferior margin, ____ cm from the deep margin, ____ cm
from the most lateral margin, and ____  cm from the most
medial margin. The remainder of the breast parenchyma is
fibro-fatty tissue (____% fibrous, ____% fatty).
Ink code:
• Superior – Blue
• Superficial – Yellow
• Inferior – Green
• Lateral – Red
• Medial – Orange
• Deep – Black
Section code:
Slice 1 (Most lateral or most medial)
• A1–A3 – In perpendicular sections
Slice 2
• A4 – Superior superficial
• A5 – Superior deep
• A6 – Superficial
• A7 – Deep
• A8 – Inferior superficial
• A9 – Inferior deep
Slice 3
• A10 – …
Etc.
Sentinel Lymph Nodes
Sentinel lymph nodes are often removed and sent for intra-
operative consultation for both mastectomy and lumpectomy
specimens (Fig.  2.10). The objective is to assess for meta-
static tumor deposits in the sentinel lymph nodes, to help
determine whether to perform an axillary dissection in
patients with breast malignancies.
Grossing Tips: Sentinel Lymph Nodes
• For sentinel lymph nodes (or generally for lymph nodes
from any body site), never put more than one bisected or
serially sectioned lymph node piece from a different
lymph node in a single cassette. This can lead to confu-
sion when lymph nodes are positive. For example, if two
lymph nodes are bisected and placed in the same cassette,
12
Fig. 2.10  Grossing sentinel lymph nodes for intraoperative consul-
tation. The lymph node is separated from surrounding fat, then seri-
ally sectioned along its long axis into thin slices. Next, touch
preparations are performed by touching the lymph node cut surface
and two of four fragments are microscopically positive, it
would not be possible to determine whether this repre-
sents one or two positive lymph nodes.
• Serially section the lymph node along the long axis.
• Touch slices to a glass slide, and also touch the opposite
surface of the slices to another glass slide.
• Place slides in alcohol immediately, followed by routine
H&E staining.
• Placing the slides in alcohol immediately after a touch
imprint is made will help avoid air-drying artifact, which
can hinder microscopic interpretation.
Suggested Reading
Agarwal S, Pappas L, Neumayer L, Kokeny K, Agarwal J.  Effect of
breast conservation therapy vs. mastectomy on disease-specific sur-
vival for early-stage breast cancer. JAMA Surg. 2014;149:267–74.
https://doi.org/10.1001/jamasurg.2013.3049.
M. B. Lemos and N. Sneige
to a slide. The lymph node slices are then flipped, and the opposite
surfaces of each lymph node piece are touched to another slide.
Slides are immediately placed into alcohol (to avoid air-drying arti-
fact) and then stained
Goodman S, O’Connor A, Kandil D, Khan A. The ever-changing role
of sentinel lymph node biopsy in the management of breast cancer.
Arch Pathol Lab Med. 2014;138:57–64. https://doi.org/10.5858/
arpa.2012-0441-RA.
Lemos M, Sahin A.  Surgical margin evaluation. In: Babiera GV,
Skoracki RJ, Esteva FJ, editors. Advanced therapy of breast dis-
ease. 3rd ed. Shelton: People’s Medical Publishing House; 2012.
p. 569–80.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J
Clin. 2019;69:7–34. https://doi.org/10.3322/caac.21551.
Stolnicu S. Prognostic and predictive factors in breast carcinoma. In:
Stolnicu S, Alvarado-Cabrero I, editors. Practical atlas of breast
pathology. Springer International Publishing; 2018. p.  327–56.
https://doi.org/10.1007/978-3-319-93257-6.
Valencia-Cedillo R.  Sampling and evaluation of the breast surgical
specimens. In: Stolnicu S, Alvarado-Cabrero I, editors. Practical
atlas of breast pathology. Springer International Publishing; 2018.
p. 475–89. https://doi.org/10.1007/978-3-319-93257-6.
Zahoor S, Haji A, Battoo A, Qurieshi M, Mir W, Shah M.  Sentinel
lymph node biopsy in breast cancer: a clinical review and update.
J Breast Cancer. 2017;20:217–27. https://doi.org/10.4048/
jbc.2017.20.3.217.
 Head and Neck
3
Monica B. Lemos and Alberto Ayala

The head and neck region, with its many organs and struc- imen is serially sectioned showing a tan-pink rubbery cut
tures, is divided into different areas, which include the oral surface. Tan-yellow granules are identified in crypts. No
cavity, pharynx, larynx, paranasal sinuses and nasal cavity. gross lesions are identified.
Head and neck pathology specimens encountered in the sur-
Sections Code:
gical pathology suite range from routine tonsil specimens to
complex specimens such as a laryngectomy. When handling
• A1 – Tonsil, representative section
head and neck specimens, an appreciation of the anatomic
landmarks is essential, and understanding the anatomic ori-
entation before specimen sectioning begins is particularly
Glossectomy
critical. A systematic approach to complex specimens will
aid in providing a thorough and complete gross examination,
Before sectioning a glossectomy specimen, the orientation of
and will help to ease any anxiety that may arise in the face of
the specimen, as designated by the surgeon, should be prop-
potentially intimidating specimens. This chapter discusses
erly understood (ie, anterior/posterior aspects). After inking
the gross examination of a variety of head and neck speci-
the resection margins, the specimen is serially sectioned
mens, as well as thyroid specimens, and includes a stepwise
(Fig. 3.4).
and straightforward approach to grossing laryngectomy
specimens.
Uvulectomy
Tonsillectomy Grossing of a uvula specimen (Fig.  3.5) is usually
straightforward.
Tonsillectomy specimens commonly have a cerebriform
appearance. After examination of the outer surface, the spec-
imen is serially sectioned (Figs. 3.1, 3.2 and 3.3).
Sample Dictation: Uvula

Received is a tan-pink smooth and glistening conical portion

Sample Dictation: Tonsillectomy
Received fresh/in formalin labeled as “_____” is a tan-pink
ovoid lobulated tonsil (____ × _____ × _____ cm). The spec-
of tissue (____ × ____ × ____ cm). The base of the specimen
is inked blue. The uvula is bisected, and the cut surface is
tan-pink and rubbery. [Describe any lesions]. The specimen
is entirely submitted in cassette A1.

M. B. Lemos (*)
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
Floor of the Mouth
e-mail: MBLemos@houstonmethodist.org
Resected specimens from the floor of the mouth should be
A. Ayala
Department of Pathology and Genomic Medicine, Houston properly oriented and inked (Figs. 3.6 and 3.7) before being
Methodist Hospital, Houston, TX, USA sequentially sectioned (Fig. 3.8).
Weill Cornell Medicine, New York, NY, USA

© Springer Nature Switzerland AG 2019 13

M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_3
14 M. B. Lemos and A. Ayala

Fig. 3.1  Tonsillectomy specimens. Right and left tonsils are shown. Note the “cerebriform” appearance and the tan-yellow “sulfur” granules,
representing Actinomyces bacterial colonies, which are commonly seen in tonsils

Fig. 3.2  Sectioned tonsils. Note the tan-pink cut surface and tan-yellow “sulfur” granules present within tonsillar crypts
3  Head and Neck 15

Fig. 3.3  Tonsil with

papilloma. This tonsil has a
papilloma in addition to the
frequently identified “sulfur”
granules

Fig. 3.4  Glossectomy. An ulcerated, mucosal-based lesion makes up (not shown is the resected surface deep to the mucosa). The medial and
the majority of the surface of this glossectomy specimen. Resection lateral halves of the specimen are inked two different colors. The speci-
margins are present circumferentially, in addition to the deep margin men is serially sectioned from anterior to posterior
16 M. B. Lemos and A. Ayala

Salivary Gland

Parotid glands and submandibular glands may be received as

part of a neck dissection, or received individually. All sali-
vary glands should be weighed, if received individually, and
not as part of a neck dissection. This section will focus on
how to handle salivary glands when received separately, and
not as part of a neck dissection.
If there is a history of tumor, or if after palpation of the
gland, a mass is felt, the outer surface of the gland should be
inked one color, before serially sectioning (Figs.  3.9, 3.10
and 3.11).

Thyroidectomy

Grossing Tips: Thyroidectomy

Fig. 3.5  Uvula. To gross this specimen, simply ink the base (resection • Always weigh thyroid specimens (total or partial) in addi-
margin), bisect, describe the cut surface and any lesions, and submit tion to measuring their dimensions.
entirely

Fig. 3.6  Floor of the mouth. This resection of a floor of the mouth tially along all the clock positions in addition to the deep margin (which
lesion is oriented by the surgeon with a long stitch at 12 o’clock and a is not shown and is on the resected surface deep to the mucosa)
short stitch at 3 o’clock. Resection margins are present circumferen-
3  Head and Neck 17

Fig. 3.7  Floor of the mouth: Margins. The left and right halves of the gin section. The margins are shaved circumferentially with care to
specimen are inked with two different colors. Dots are placed along the include a portion of mucosa in each section
various o’clock positions to give a more precise location for each mar-

Fig. 3.8  Floor of the mouth:

Sectioning. After submitting
the margins, the specimen is
sectioned sequentially along
the 12 to 6 o’clock direction.
Serial sections should be
examined for depth of
invasion of the lesion. If a
frozen section is requested
and the lesion comes close to
the deep margin, an additional
section of the deepest
invasion may be required. The
specimen should be submitted
entirely and sequentially from
12 to 6 o’clock
18
Fig. 3.9  Submandibular gland. This submandibular gland resection
specimen included attached fibroadipose tissue. The specimen should
be first weighed. Note the ovoid, lobulated, and smooth surface of the
submandibular gland, which is different from the more rough and irreg-
ular surface of a parotid gland. The fat should be sectioned to look for
Fig. 3.10  Parotid gland. Shown here is a parotid gland and following
serial sections. Before sectioning, the specimen should be weighed and
palpated for any masses. Note the rough and irregular surface. In this
• The convex side is anterior; the concave side is posterior
(Fig. 3.12).
• Ink the anterior surface, posterior surface, and isthmus
each a different color (Fig. 3.13).
• It is useful to use the same colors consistently to ink thy-
roid specimens. That way, if the ink code is lost, one will
still know which colors were used for each part of the
specimen.
• Section the specimen from superior to inferior (Fig. 3.14).
• Keep the sections laid out as corresponds to the normal
thyroid (i.e., superior up and inferior down, with the left
lobe sections on the left and the right lobe sections on the
right) (Fig. 3.15).
• Examine the cut surface for any nodules and describe the
appearance of any noted nodules.
M. B. Lemos and A. Ayala
lymph nodes. In this case, there was no history of tumor, and no mass
was palpated, thus the outer surface of the specimen was not inked. The
gland tissue is subsequently serially sectioned to look for lesions. In this
case, serial sections of the submandibular gland showed an unremark-
able cut surface
case, there was no history of tumor, and no mass was palpated, so the
outer surface was not inked before the specimen was serially sectioned.
The cut surface of this serially sectioned parotid is grossly unremarkable
• Nodules may have areas of hemorrhage due to degenera-
tive change or due to prior fine needle aspiration
• Note if the nodule is encapsulated or not. For encapsu-
lated nodules, it is important that sections include the
entire capsule (capsular-parenchymal interface).
• Papillary thyroid carcinomas often have a gray-white or
tan-brown cut surface. Associated calcifications may also
be noted, as well as cystic change.
• Follicular carcinomas are encapsulated and have a thicker
capsule than adenomas.
• Submit sections in sequential order from most superior to
inferior, even if the sections are only representative
sections.
3  Head and Neck 19

Fig. 3.11  Parotid gland with tumor. The cut surface of this parotid gland shows a tumor, which is distinct from the grossly normal surrounding
cut surface. Note that the outer surface of the parotid has been inked (black)

Fig. 3.12  Total thyroidectomy. Note the positions of right and left lobes and the isthmus. Also, note that the posterior surface is more roughened
and concave than the anterior thyroid surface

Sample Dictation: Thyroid
Received fresh/in formalin labeled as “______” is a total thy-
roidectomy specimen (or right/left thyroid lobe) (_____
grams, ____ × ____ × ____ cm right lobe, ____ × ____ × ____
left lobe, and ____ × ____ × ____ cm isthmus). The capsular
surface is intact/disrupted.
The specimen is serially sectioned and in the superior/mid
portion/inferior aspect of the left/right thyroid lobe, there is a
______ cm tan-gray/yellow, firm/gelatinous/calcified nod-
ule, well-circumscribed nodule (or multiple nodules ranging
from ____ cm to ____ cm in greatest dimension). The
remainder of the thyroid parenchyma is dark-red and
homogeneous.
20 M. B. Lemos and A. Ayala

Fig. 3.13  Total thyroidectomy: Inking. The anterior surface of both right and left lobes is inked blue, except for the isthmus, which is inked red.
The posterior surface of both right and left lobes is inked black, except for the isthmus, which is again inked red

Fig. 3.14 Total
thyroidectomy: Sectioning.
Sectioning of the thyroid is
done from superior to inferior
while keeping track of
sections from each lobe (right,
left, or isthmus). Depending
on the type of case, the
specimen may be submitted
entirely or representative
sections may be taken. In this
particular case, there was a
diagnosis of papillary thyroid
carcinoma, thus the entire
thyroid was submitted
3  Head and Neck
Fig. 3.15  Thyroid nodules. Thyroid nodules with various gross appearances
Fig. 3.16  Laryngectomy: Anterior aspect (post-formalin fixation) and
inking. The anterior right surface of the laryngectomy is inked one
color, and the anterior left side is inked another color. The epiglottis
Ink Code:
• Blue – Anterior thyroid surface
• Black – Posterior thyroid surface
• Red – Anterior and posterior isthmus
Section Code:
Serial sections from superior to inferior, as follows:
• A1–A11 – Left lobe, from superior to inferior sequentially
• A12–18 – Isthmus from left to right
• A19–29 – Right lobe, from superior to inferior sequentially
21
should also be inked a third color. This specimen includes a tracheos-
tomy site, which is inked in yellow around the skin
Laryngectomy
Grossing Tips: Laryngectomy
• Ink the left and right anterior surfaces (Fig. 3.16) and the
left and right posterior surfaces (Figs. 3.17 and 3.18) with
four separate colors.
• If a tracheostomy is present, ink the resection margin
there with an additional color.
• If the thyroid is present, keep it attached, and ink its left
and right anterior surfaces (as one would ink a specimen
without a thyroid).
22 M. B. Lemos and A. Ayala

Fig. 3.17  Laryngectomy: Posterior aspect (fresh, pre-formalin fixation). The posterior aspect of the laryngectomy specimen includes the struc-
tures and margins shown

Fig. 3.18 Laryngectomy:
Posterior aspect inking. The
laryngectomy is opened with
a longitudinal cut along the
middle of the posterior
surface. Similar to the anterior
side, the left posterior surface
in inked one color and the
right posterior surface is
inked another color. The
tracheal margin is inked in a
third color
3  Head and Neck
• If a thyroid is present, include it in the sections to evaluate
invasion into the thyroid.
• Open the specimen along its posterior surface. Cut along
the midline (Fig. 3.19).
• Look for abnormalities or tumor, and if present, measure
the size and comment on the location.
• Take the tracheal margin for frozen section.
• Also, take sections of the right and left mucosal margins.
• Place a wooden stick to keep the specimen open as it fixes
(Fig. 3.20).
• After fixing, take serial perpendicular sections of the epi-
glottis and serial perpendicular transglottic sections.
Mark slices with tumor or any other abnormalities with a
broken wooden stick. This will make it easy to keep track
of which areas are abnormal and should be submitted.
• Separate the sections to those that are supraglottic/glottic
and subglottic, and submit sequentially as follows:
–– Posterior left: submit from mid to lateral
–– Anterior left: submit from lateral to mid
–– Anterior right: submit from mid to lateral
–– Posterior right: submit from lateral to mid
• If a tumor is located posteriorly, near the pyriform sinus,
take sections horizontally and submit from superior to
inferior in that area (Fig. 3.21).
• In sections of the supraglottis/glottis, place a dot of ink on
each section to indicate the supraglottic aspect (Fig. 3.22).
Fig. 3.19  Laryngectomy: Opened view. Note the normal anatomic
structures seen on the inside of this opened laryngectomy. The subglot-
tis is located approximately 1  cm below the commissure. A tumor is
23
This makes it easier to identify true and false vocal cords
microscopically.
Sample Dictation: Laryngectomy
Received fresh labeled as “____” is a total laryngectomy
specimen (___  ×  ___  ×  ___  cm) including a hyoid bone
(___ × ___ × ___). A right/left/right and left thyroid lobe is
attached to the specimen (___ × ___ × ___). On the anterior
aspect is a tracheostomy site with tan white/brown skin
(___ cm length and ___ cm width). The specimen is opened
posteriorly and shows a ___ × ___ × ___ cm gray-white fri-
able/ulcerated/nodule/lesion located at the supraglottis/glot-
tis/subglottis and ___ cm above/below the commissure, ___
cm from the distal tracheal margin, and ___ cm from the
mucosal margin. The tumor grossly appears/does not appear
to infiltrate into the lamina propria and appears/does not
appear to infiltrate the thyroid. The lesion does/does not
grossly involve the true/false vocal cord(s). The remainder of
the mucosa is tan/pink and unremarkable/with edema etc.
Ink code:
• Blue – Right anterior surface of larynx
• Black – Left anterior surface of larynx
• Red – Epiglottis
• Yellow – Tracheostomy site
located beneath the epiglottis. Note the formalin-fixed and sectioned
specimen to the right, which separates epiglottis, supraglottis/glottis,
and subglottis
24 M. B. Lemos and A. Ayala

Fig. 3.20  Laryngectomy: Opened view after fixation. The opened laryngectomy specimen is held open with a small wooden stick and fixed in
formalin overnight. Note again the anatomic structures

Fig. 3.21  Laryngectomy: Sectioning. Serial sections are made across the tumor in the pyriform sinus
3  Head and Neck 25

Fig. 3.22  Laryngectomy: Sections. Sections are divided into those tumor. Also, the sections of supraglottis/glottis are inked with a dot on
from the epiglottis, supraglottis/glottis, and subglottis. Supraglottis/ their superior aspect (supraglottic surface) to help keep track of their
glottis sections are made to include both true and false vocal cords. orientation
Note the wooden stick pieces placed to keep track of the sections with

• Orange – Left posterior surface Suggested Reading

• Red – Right posterior surface
• Purple – Tracheal margin Faquin W.  The thyroid gland: recurring problems in histologic and
cytologic evaluation. Arch Pathol Lab Med. 2008;132(4):622–32.
Gnepp DR, Barnes L, Crissman J, Zarbo R. Recommendations for the
Section Code: reporting of larynx specimens containing laryngeal neoplasms. Am
J Clin Pathol. 1998;110:137–9.
• A1 – Epiglottis, representative sections Helliwell TR, Giles TE. Pathological aspects of the assessment of head
and neck cancers: United Kingdom National Multidisciplinary
• A2–A4 – Supraglottis and glottis, posterior left, submit- Guidelines. J Laryngol Otol. 2016;130(Suppl S2):S59–65. https://
ted from mid to lateral doi.org/10.1017/S0022215116000451.
• A5–A8 – Supraglottis and glottis, anterior left, submitted Hiatt JL, Gartner LP. Palate, pharynx, and larynx. In: Textbook of head
from lateral to mid and neck anatomy. 4th ed. Philadelphia: Lippincott Williams &
Wilkins; 2009. p. 243–62.
• A9–A15 – Supraglottis and glottis, anterior right, submit- Lydiatt WM, Patel SG, Ridge JA, O’Sullivan B, Shah JP. Staging head
ted from mid to lateral and neck cancers. In: Amin MB, editor-in-chief. AJCC cancer
• A16–A20 – Supraglottis and glottis, posterior right, sub- staging manual. 8th ed. Chicago: American College of Surgeons;
mitted from lateral to mid 2018.p. 55–65. https://doi.org/10.1007/978-3-319-40618-3.
• A21–A24 – Subglottis, representative sections, posterior
left, submitted from mid to lateral
• A25–A29  – Subglottis, representative sections, anterior
left, submitted from lateral to mid
• A30–A33  – Subglottis, representative sections, anterior
right, submitted from mid to lateral
• A34–A39 – Subglottis, representative sections, posterior
right, submitted from lateral to mid
 Gastrointestinal Tract
Monica B. Lemos and Mary Schwartz
Gastrointestinal tract specimens are among those most com-
monly received in the surgical pathology grossing suite.
Besides the numerous gastrointestinal tract biopsy speci-
mens, many of the more common larger routine specimens
come from the gastrointestinal tract, including appendec-
tomy, cholecystectomy, and colectomy specimens. Standard
gross evaluation and sectioning is recommended, regardless
of the apparent presence or absence of a neoplastic lesion.
This procedure ensures that if an unexpected neoplasm is
discovered microscopically, the important information
needed, such as margin status, will be documented. This
chapter provides instruction on grossing many of the various
types of gastrointestinal tract specimens that may be encoun-
tered in the surgical pathology grossing suite.
Esophagogastrectomy
Specimens include portions of the esophagus and stomach
(Figs. 4.1 and 4.2).
Sample Dictation: Gastrectomy
Received fresh/in formalin labeled as “_____” is a total/sub-
total gastrectomy specimen. The specimen measures ___ cm
along the greater curvature and ___ cm along the lesser cur-
vature. The circumference ranges from ___ cm at the proxi-
mal margin to ___ cm at the distal margin. A portion of the
duodenum is present (___ cm in length and ___ cm in cir-
cumference). The serosal surface is tan-pink smooth and
glistening/includes an area of adhesions or perforation (areas
of adhesions or perforation are inked ___). The wall thick-
ness is ___ cm.
M. B. Lemos (*) · M. Schwartz
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
e-mail: MBLemos@houstonmethodist.org
© Springer Nature Switzerland AG 2019
M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_4
4
The specimen is opened through the greater curvature and
reveals a ___  ×  ___  cm friable/fungating/polypoid firm
tumor located on the greater/lesser curvature or in the cardia/
fundus/antrum/pre-pyloric region. The tumor is ___ cm from
the proximal margin and ___ cm from the distal margin. The
tumor grossly invades/does not invade through the muscula-
ris propria and invades/does not invade into the perigastric
soft tissue. The remainder of the mucosa is unremarkable,
with normal folds. In the attached perigastric adipose tissue
are __# lymph nodes ranging in size from ___ to ___ cm.
Ink code:
• Blue – Proximal margin
• Black – Distal margin
Section code:
• A1 – Proximal margin
• A2 – Distal margin
• A3–A10 – Tumor
• A11 – Normal stomach
• A12 – Lymph nodes
Sample Dictation: Esophagectomy
Received fresh/in formalin labeled as “____” is an esopha-
gectomy specimen (___ cm in length and ___ cm in circum-
ference) with a small attached portion of stomach (___ cm in
length and ___ cm in circumference). The serosal surface is
tan-pink and smooth with attached adipose tissue.
The mucosal surface reveals a ___ × ___ cm tan/tan-gray
firm friable/fungating mass located at the gastroesophageal
junction, which invades/does not invade the muscularis pro-
pria and soft tissue. The tumor is ___ cm from the proximal
margin and ___ cm from the distal margin. The remainder of
the mucosa is unremarkable. The stomach mucosa is tan/pale
tan/erythematous with normal folds. In the paraesophageal
27
28 M. B. Lemos and M. Schwartz

Fig. 4.1  Esophagogastrectomy. Note the presence of esophagus and a portion of the proximal stomach with staples along the surgical resection
margin. Cut directly under the staples and ink this resection margin

Fig. 4.2 Esophagogastrectomy: Opened. The stomach should be geal junction. Take longitudinal sections of the area with a tumor. Also
opened along the greater curvature. Note the esophageal mucosa and a submit the proximal and distal margins
rugated portion of gastric mucosa. There is a tumor at the gastroesopha-
4  Gastrointestinal Tract 29

tissue, __# of lymph nodes are identified ranging from ___ to
___ cm. In the paragastric tissue, __# lymph nodes are iden-
tified ranging from ___ to ___ cm.
Ink code:
intestinal neoplasms, and bowel injuries, among others. After
reversal of an ileostomy, an ileostomy specimen may be
received in the surgical pathology grossing suite (Figs. 4.3
and 4.4).

• Blue – Proximal (esophageal) margin

• Black – Distal (stapled gastric) margin Sample Dictation: Ileostomy

Section code: Received fresh/in formalin and labeled as “_____” is an ile-

ostomy specimen (____ cm length, ____ cm circumference).
• A1 – Proximal margin An ostomy site is present (____  cm diameter). A tan-gray
• A2 – Distal margin rim of skin surrounding the ostomy site is present (____ cm
• A3–A10 – Tumor width). The serosa is tan-white. The mucosa is tan with nor-
• A11–A12 – Normal esophagus mal folds, and no gross lesions are identified. The wall of the
• A15 – Stomach mucosa bowel is ____ cm thick.
Section code:

Ileostomy • A1, A2 – Margins

• A3–A4 – Representative sections
Various bowel conditions may require a temporary ileos-
tomy. Such conditions include inflammatory bowel disease,

Fig. 4.3  Ileostomy. This specimen consists of a portion of bowel with a rim of skin. Measure the ostomy site diameter and the rim of skin sur-
rounding the ostomy site
30
Fig. 4.4  Ileostomy: Sectioning. Open the stapled end by cutting beneath the staples. Cut through the ostomy site. Take sections so that both the
skin and mucosa are included
Small Bowel
A portion of the small bowel may be resected because of a
tumor (Figs. 4.5 and 4.6) or diverticulum (Fig. 4.7), among
other indications.
Large Bowel
Segments of the large bowel may be resected because of
tumors (Figs. 4.8, 4.9, 4.10, 4.11, 4.12 and 4.13), diverticuli-
tis (Figs. 4.14, 4.15, 4.16 and 4.17), inflammatory bowel dis-
ease (Figs. 4.18, 4.19 and 4.20), or ischemia (Figs. 4.21 and
4.22), among other indications.
Grossing Tips: Large Bowel
Colon with a neoplasm:
• Ink the serosal surface and fat overlying the tumor to aid
in the determination of the extent of invasion of the tumor
into the colonic wall upon microscopic examination.
M. B. Lemos and M. Schwartz
• Ink the proximal and distal margins different colors.
• After opening the colon, determine the location of the
tumor and its size and distance from margins (Figs. 4.8
and 4.9).
• Take the fat off the serosa, except for the fat in the area of
tumor. Keep separate the fat proximal to the tumor and the
fat distal to the tumor (Fig. 4.10).
• Take longitudinal sections (i.e., parallel to the length of
the colon) of tumor to help show the relationship of the
tumor to the adjacent normal bowel and other adjacent
structures (Fig. 4.11).
• Be sure to include sections of the deepest gross invasion
of the tumor (e.g., into the muscle wall or pericolonic
fat).
• If the tumor is very close to the proximal or distal margin
of resection, take perpendicular sections to include the
margin as well as the tumor. Otherwise (if the tumor is
further away from the margins), submit the margins en
face (Figs. 4.12 and 4.13).
• Look for lymph nodes in the fat and submit separately
those from the proximal fat, the distal fat, and the peritu-
moral fat.
4  Gastrointestinal Tract 31

Fig. 4.5  Small bowel: Resection of subserosal tumor. Note the peritonealized surface and both the bowel and tumor resection margins

Fig. 4.6  Small bowel: Inking and sectioning of subserosal tumor. The The tumor is then serially sectioned. Note the change in the appearance
soft tissue resection margin adjacent to the tumor is inked one color, of the bowel mucosal surface in the area involved by the tumor
and the peritoneal surface adjacent to the tumor is inked another color.

Fig. 4.7  Meckel’s diverticulum. Intact (left) and bisected (right) Meckel’s diverticulum specimen. There is an area of gastric-type mucosa that can
be appreciated grossly and microscopically. (H&E image courtesy of Andreia Barbieri, MD, Houston Methodist Hospital)
32 M. B. Lemos and M. Schwartz

Fig. 4.8  Right hemicolectomy. This specimen includes a portion of the its distance to proximal and distal margins should be recorded. It is also
ileum, cecum, and right colon. An exophytic mass is located adjacent to helpful to ink the proximal and distal margins before taking sections
the ileocecal valve in the cecum. The position of the tumor, its size, and

Fig. 4.9 Right
hemicolectomy: Inking.
Inking the serosa and
pericolonic fat overlying the
tumor helps when assessing
the depth of tumor invasion
4  Gastrointestinal Tract 33

Fig. 4.10  Rectum: Radial margin. The radial margin is the non-peritonealized bare area of the rectum, located anteriorly and posteriorly. This
represents tissue through which the surgeon has cut

Fig. 4.11  Colon tumor: Longitudinal sectioning. Longitudinal sections help show the relationship of the tumor to adjacent structures. This can be
especially important when the tumor is very close to one of the margins
34 M. B. Lemos and M. Schwartz

Fig. 4.12  Rectum with anal mucosa and dentate line. The anatomy of should be noted whether any tumor in this area crosses or involves the
the dentate line is demonstrated in this gross image and corresponding dentate line, as does the tumor in this specimen. (Sketch courtesy of
sketch. The dentate line divides the upper two thirds and lower one third Ahmed Shehabeldin, MD, Houston Methodist Hospital.)
of the anal canal; it is located at the inferior limit of the anal valves. It

Fig. 4.13  Colon tumor:

Depth of invasion. It is
important to assess the depth
of invasion of colon tumors
grossly and to submit sections
of the deepest areas seen.
Sectioning this tumor shows
grossly apparent invasion into
the fat and a lymph node
grossly positive for metastasis

Colon with diverticula:
• Before cutting into the specimen, look carefully at the
outside surface for areas of serosal exudate or adhesions
(Figs. 4.14 and 4.15). These areas could represent sites of
perforation.
• If an area of adhesion is identified, ink this area, but
remove the non-inflamed adipose tissue.
• Take longitudinal sections, as this helps to identify the
diverticula (Figs. 4.16 and 4.17).
Colon with inflammatory bowel disease:
• In cases of inflammatory bowel disease (ulcerative colitis
and Crohn’s disease), make sure to document the distribu-
tion (patchy vs. continuous) of mucosal changes (mucosal
eryhthema, ulceration, pseudopolyps, etc); as well as the
presence or absence of strictures (Fig.  4.18, 4.19 and
4.20).
• Make sure to evaluate for any nodules or massess.
• Numerous lymph nodes are often present in the peri-­
intestinal adipose tissue. It is not uncommon to identify
dozens of lymph nodes, in cases of inflammatory bowel
disease.
Colon with ischemia:
• Evaluate the serosal surface and note for changes in color.
The serosal surface is often dark, and has a dusky apper-
ance (Fig. 4.21)
4  Gastrointestinal Tract 35

Fig. 4.14  Diverticulitis. When grossing a colon with diverticular disease, identify areas of adhesions or exudate on the surface first. These areas
may represent sites of diverticular rupture or colon perforation

Fig. 4.15 Diverticulitis:
Adhesions. Seen here are
adhesions on the surface of a
colon with diverticulitis

Fig. 4.16 Diverticular
disease: Mucosal surface.
Several diverticular openings
are apparent on the mucosal
surface of this segment of
bowel
36 M. B. Lemos and M. Schwartz

Fig. 4.17  Diverticula: Sections. Longitudinal sections need to be taken to identify and submit diverticula. Once identified, submit diverticula for
microscopic examination. These sections should include the entire depth of the diverticulum into the colonic wall

Fig. 4.18  Colon with

ulcerative colitis. Note the
multiple pseudopolyps and
diffuse mucosal involvement
of the large bowel

Fig. 4.19  Colon with

Crohn’s disease. Note the
patchy distribution of affected
colon and mucosal erythema.
Also seen is the “cobblestone”
mucosa characteristic of
Crohn’s disease
4  Gastrointestinal Tract 37

Fig. 4.20  Colon with

Crohn’s disease: Stricture.
Strictures such as this are
common findings in Crohn’s
disease

Fig. 4.21  Bowel with adhesed ovary. This bowel shows features of ischemia and has a dusky serosal surface, as well as serosal exudates.
Extensive adhesions are present, including adhesion of an ovary. Due to the dense adhesions, the ovary was surgically resected along with the colon

• Evaluate for any adhesions, serosal exudate, or perforations.
• Examine the appearance of the mucosa, noting if the
mucosal folds appear depressed, flattened, or discolored.
• Examine the blood vessels to evaluate for any grossly
obvious sites of thrombosis or other vascular lesion.
• In some cases of ischemia with associated rupture and
adhesions, there may be adhesions to other structures.
Note the adhesed ovary in Figs. 4.21 and 4.22. The area
of adhesion between the ovary and colon is inked green.
In addition to submiting bowel margins and represena-
tive sections of bowel wall, sections at the site of adhe-
sions are taken to microscopicaly examine the
relationship between the colon and ovary.
38
Fig. 4.22  Bowel with adhesed ovary: Opened. The area of adhesions is inked in green, after which the ovary is bisected and examined. In this
case, the ovary happened to be cystic
 ample Dictation: Right Hemicolectomy/
S Section code:
Ileocolectomy
Received fresh/in formalin and labeled as “_____” is a seg-
ment of terminal ileum (____ cm length, _____ cm circum-
ference), cecum (____ × ____ cm) and right colon (____ cm
length, ____  cm circumference). An appendix is present
(____ cm length, ____ cm circumference) (or the appendix
is not identified). The serosal surface is tan-pink and smooth/
with an area of adhesion measuring ___ × ___ cm and located
___ cm from the proximal margin and ___ cm from the distal
margin. There is attached adipose tissue along the entire
length of the specimen.
A fungating/ulcerated and firm tan-brown mass
(____ × ____ × ____ cm) is located in the cecum/ileocecal
valve/ascending colon. The tumor grossly invades/does not
invade the muscularis propria/pericolic fat. The tumor is
located ____  cm from the proximal margin and ____  cm
from the distal margin.
There are ____ # polyps (____ cm to ____ cm in greatest
dimension) located in _____, and are present ____ cm from
the tumor and _____ cm from the closest margin. __# ­possible
lymph nodes are identified in the pericolic adipose tissue.
Ink code:
• Black – Radial or mesenteric margin
• Blue – Serosa underlying tumor
• Orange – Proximal margin
• Green – Distal margin
M. B. Lemos and M. Schwartz
• A1 – Proximal margin∗
• A2 – Distal margin∗
• A3 – Radial/mesenteric margin
• A4 – Tip of the appendix, bisected
• A5 – Representative cross-sections of appendix
• A6–A10 – Mass
• A11 – Polyp #1
• A12 – Polyp #2
• A13  – Non-neoplastic right colon, representative
section
• A14–A16 – Lymph nodes from adipose tissue proximal to
tumor
• A17–A19  – Lymph nodes from peritumoral adipose
tissue
• A20–A22  – Lymph nodes from adipose tissue distal to
tumor
∗Note: Submit margin(s) perpendicularly, if close to the
tumor.
Sample Dictation: Low Anterior Resection
Received fresh/in formalin labeled as “____” is a segment
of sigmoid colon (____  cm length, ____  cm circumfer-
ence), a segment of rectum (____ cm length, ____ cm cir-
cumference) with perirectal and mesenteric adipose tissue.
The serosal surface is tan-pink, and an area of adhesion is
4  Gastrointestinal Tract
identified measuring ____  ×  ____  cm and ____  cm from
the proximal margin and ____ cm from the distal margin.
Perirectal and mesenteric adipose tissue is present.
A ____ × ____ × ____ cm firm tan-brown and ulcerated/
fungating mass is located in the sigmoid colon/rectum, and is
____ cm from the proximal margin, ____ cm from the distal
margin, and ____  cm from the radial margin. The tumor
grossly invades/does not invade the muscularis propria/peri-
colic adipose tissue.
There are ____ # polyps (____ cm to ____ cm in greatest
dimension) located in _____ and present ____ cm from the
tumor, and _____  cm to the closest margin. __# possible
lymph nodes are identified in the pericolic adipose tissue.
Ink code:
• Black – Radial margin
• Blue – Proximal margin
• Orange – Distal margin
Section code:
• A1 – Proximal margin
• A2 – Distal margin
• A3 – Radial margin (if rectal tumor)
• A4–A10 – Mass
• A11 – Polyp #1
Fig. 4.23  Appendectomy. When received, measure the appendix and
always ink the proximal margin. Then examine the serosal surface for
abnormalities, including exudate and perforation. The distal tip should
be bisected and submitted entirely. Also submit the inked proximal mar-
gin. (This can be submitted in the same cassette as the tip.). Finally,
39
• A12 – Polyp #2
• A13  – Non-neoplastic sigmoid colon, representative
section
• A14 – Non-neoplastic rectum, representative section
• A15–A16 – Lymph nodes from adipose tissue proximal to
tumor
• A17–A19  – Lymph nodes from peritumoral adipose
tissue
• A20–A22  – Lymph nodes from adipose tissue distal to
tumor
∗Note: If the tumor is very close to the margins, take per-
pendicular sections.
Appendectomy
Figure 4.23 illustrates the grossing of an appendix. Serosal
exudate (Fig. 4.24) is not always seen.
Sample Dictation: Appendix
Received fresh/in formalin and labeled as “______” is an
appendectomy specimen with a small amount of peri-­
appendiceal fat. The appendix is ____  cm in length and
serially section the appendix and submit representative cross-sections. If
the appendix appears grossly normal but appendicitis is suspected clini-
cally, the entire appendix should be submitted for microscopic examina-
tion. In these images, note the blue ink on the proximal margin, the
presence of a fecalith within the lumen, and the bisected appendix tip
40 M. B. Lemos and M. Schwartz

Fig. 4.24 Appendix:
Purulent serosal exudate.
Note the presence of
tan-white exudate material at
the tip of this appendectomy
specimen

Fig. 4.25  Polypectomy. Seen here is a polyp with its stalk. The base of Alternatively, both ends of the polyp can be submitted in a single cas-
the polyp (tip of the stalk) should be inked. When no stalk is present, sette, as long as it is indicated in which cassettes the ends are
ink the base of the polyp. The polyp is serially sectioned parallel to the submitted
stalk and submitted sequentially from one end to the opposite end.

____ cm in diameter. The proximal margin is inked blue. The Polypectomy

outer appendiceal surface is tan-pink and smooth/with areas
of serosal exudate. The specimen is serially sectioned, and Figure 4.25 illustrates the grossing of a polyp, including
the lumen ranges from ____ cm to _____ cm in diameter. No serial sectioning.
fecaliths or perforations are present (or the lumen is partially
filled with fecaliths or purulent material).
Ink code: Sample Dictation: Polypectomy

• Blue – Proximal margin Received fresh/in formalin and labeled “polyp” is a tan-pink/
red-brown polyp measuring __ × ___ × ___ cm with a stalk
Section code: present measuring ____  cm in diameter and ____  cm in
length. The base of the polyp is inked blue. The specimen is
• A1 – Tip of the appendix bisected and entirely submitted; serially sectioned. The cut surface is tan-pink and rubbery/
proximal margin ink side down slightly friable. It is entirely submitted sequentially from one
• A2 – Representative cross-sections of appendix end to the opposite end in cassettes A1–A__.
4  Gastrointestinal Tract
Suggested Reading
Burroughs SH, Williams GT. Examination of large intestine resection
specimens. J Clin Pathol. 2000;53:344–9. https://doi.org/10.1136/
jcp.53.5.344.
Glickman JN, Odze RD.  Epithelial neoplasms of the esophagus. In:
Odze RD, Goldblum JR, editors. Surgical pathology of the GI
tract, liver biliary tract and pancreas. Philadelphia: Elsevier; 2015.
p. 674–709.
Plesec TP, Owens SR.  Inflammatory and neoplastic disorders of the
anal canal. In: Odze RD, Goldblum JR, editors. Surgical pathol-
ogy of the GI tract, liver biliary tract and pancreas. Philadelphia:
Elsevier; 2015. p. 887–918.
41
Poulin EJ, Shen J, Gierut JJ, Haigis KM.  Pathology and molecular
pathology of colorectal cancer. In: Loda M, Mucci L, Mittelstadt
M, Van Hemelrijck M, Cotter M, editors. Pathology and
­epidemiology of cancer. Cham: Springer; 2017. p. 409–46. https://
doi.org/10.1007/978-3-319-35153-7_22.
Royston D, Warren B.  Pathology of anorectal and colonic speci-
mens. In: Givel JC, Mortensen N, Roche B, editors. Anorectal and
colonic diseases. Berlin: Springer; 2010. p.  81–115. https://doi.
org/10.1007/978-3-540-69419-9_7.
Shen S, Haupt B, Ro J, Baily HR, Schwartz M.  Number of lymph
nodes examined and associated clinicopathologic factors in colorec-
tal carcinoma. Arch Pathol Lab Med. 2009;133:781–6. https://doi.
org/10.1043/1543-2165-133.5.781.
 Hepatobiliary and Pancreas
Monica B. Lemos and Mary Schwartz
The volume of hepatobiliary and pancreatic specimens
received in the surgical pathology grossing suite is highly
dependent on the individual hospital practice setting. Some
of these specimens, such as pancreaticoduodenectomy speci-
mens, can be very complex. A pancreaticoduodenectomy
procedure, also known as a Whipple procedure, includes
resection of the head of the pancreas, a portion of the bile
duct, a portion of the distal stomach, and a portion of the
duodenum. Whipple procedures are typically performed for
resection of tumors in the head of the pancreas, distal com-
mon bile duct, or ampulla of Vater. Whipple procedure speci-
mens are one of the most anxiety-inducing specimens
encountered by pathology trainees and practitioners unfamil-
iar with such specimens. In practice settings where these sur-
geries are performed infrequently, acquiring confidence in
handling such specimens may be challenging. This chapter
outlines step-by-step procedures on how to handle hepatobi-
liary and pancreatic specimens, including pancreaticoduode-
nectomy specimens, and gives helpful tips on how to properly
orient these specimens upon their receipt in the grossing
suite.
Hepatectomy
Grossing Tips: Hepatectomy
• Draw the outlines of the liver segment surfaces with a
light-colored ink (yellow works best). Then, with a differ-
ent color, blot each segment’s surface inside the lines
drawn (Figs. 5.1, 5.2, 5.3, 5.4 and 5.5). This method will
reduce the time required to ink the entire liver.
• Do not forget to take vascular and hepatic duct margins
before serially sectioning the liver (Figs. 5.6 and 5.7).
M. B. Lemos (*) · M. Schwartz
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
e-mail: MBLemos@houstonmethodist.org
© Springer Nature Switzerland AG 2019
M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_5
5
Sample Dictation: Hepatectomy
Received fresh/in formalin is a hepatectomy specimen
(____  grams, ____  ×  ____  ×  ____  cm) with an attached
intact gallbladder (____  cm length, ____  cm maximum
circumference).
The liver capsule is red-brown and smooth (or, for a cir-
rhotic liver, diffusely nodular with nodules ranging from
____ cm to ____ cm). There is a ____ cm retracted area on
the surface. The specimen is serially sectioned, and there is a
____ × ____ × ____ cm tan-gray mass located in segment #
____ (describe any additional characteristics of the mass
such as areas of necrosis, hemorrhage, calcification, etc.).
The mass is ____ cm from the capsular surface.
The gallbladder surface is tan-pink with a ____ cm cystic
duct. There is dark green bile within the gallbladder lumen.
The mucosa is green with yellow-speckled areas, consistent
with cholesterolosis (or velvety green and trabeculated). The
wall of the gallbladder is ____ cm thick.
Ink code:
• Black – Segment VIII surface
• Purple – Segment II surface
• Orange – Segment III surface
• Red – Segment IV surface
• Yellow – Segment V surface
• Blue – Segment VI surface
• Green – Segment VII surface
• No color – Caudate surface
Section code:
• A1 – Hepatic duct and vascular margins
• A2–A6 – Lesion in segment # ____
• A7  – Representative section of liver parenchyma from
segment # ____
• A8 – Representative section of gallbladder
43
44 M. B. Lemos and M. Schwartz

Fig. 5.1  Hepatectomy. Note

the right and left lobes,
falciform ligament, and
caudate lobe, as seen in this
anterior view of a total
hepatectomy specimen

Fig. 5.2  Hepatectomy: Segments in anterior view. The liver is divided Fig. 5.3  Hepatectomy: Segments in posterior view. Note also the posi-
into eight anatomical segments tion of the attached gallbladder

Fig. 5.4  Hepatectomy: Inking (anterior). The liver surface is inked with different colors for each of the anatomic segments. The inking will aid in
describing the location of lesions with respect to the segments after the liver is serially sectioned (see Figs. 5.6 and 5.7)
5  Hepatobiliary and Pancreas 45

Fig. 5.5  Hepatectomy: Inking (posterior). Inking of the liver segments posteriorly, using the same colors as for anterior inking

Fig. 5.6  Hepatectomy: Sectioning. Thin serial sections should be the lesion(s) is located in. This will allow the prosector to pay additional
made to look closely for any abnormality or mass. It is helpful to review attention to this segment(s), in order to identify the radiographically
any available preoperative radiographic imaging of the liver to see if detected lesion(s)
any lesions were identified radiographically, and if so, which segment
46 M. B. Lemos and M. Schwartz

Fig. 5.7  Hepatectomy: Serial sections with tumor. After inking the surface of the different liver segments and thinly sectioning the liver, the loca-
tion of any tumor in serial sections can be identified. Note the tan-white mass seen here

Fig. 5.8 Cholecystectomy. This cholecystectomy specimen has a node. Do not forget to assess whether a pericystic lymph node is present
smooth serosal surface, roughened hepatic aspect (where the surgeon before grossing the rest of the gallbladder
dissected the gallbladder off the liver surface), and a pericystic lymph

Cholecystectomy Sample Dictation: Cholecystectomy

After examining the surface of the gallbladder (Fig. 5.8) and Received in formalin labeled “gallbladder” is an intact/pre-
submitting the cystic duct margin (Fig. 5.9), open the gall- viously opened gallbladder (____  cm length and ____  cm
bladder, examine the mucosal surface, and take representa- maximum circumference) with a cystic duct. The serosal
tive sections (Fig. 5.10). surface is tan-green/green, etc. The bile is dark green. The
5  Hepatobiliary and Pancreas
Fig. 5.9  Cholecystectomy: Cystic duct margin. The cystic duct margin is usually stapled or clipped and should be submitted (en face)
Fig. 5.10  Cholecystectomy: Sectioning. The gallbladder is opened
and its contents, which consist of bile and possibly stones, are removed.
Then the mucosal surface can be examined. This picture shows gall-
bladder mucosa with a characteristic yellow-spotted appearance indi-
mucosa is velvety and green/pink-green and trabeculated/
with cholesterolosis/with multiple yellow granular polyps
(____ cm to ____ cm in greatest dimension). The wall of the
gallbladder measures ____ cm in thickness. Multiple green/
black/yellow-green and smooth/granular/irregularly shaped
gallstones are present (____ to ____ cm in greatest dimen-
sion). A ____ cm tan-pink single lymph node is identified.
Section code:
• A1  – Representative section of the gallbladder (include
cystic duct margin and three sections of gallbladder)
• A2 – Lymph node (if present)
47
cating cholesterolosis. Representative sections of the gallbladder are
submitted; these sections are made longitudinally to include the great-
est surface area possible for examination
Whipple Resection
(Pancreaticoduodenectomy)
Grossing Tips: Whipple Resection
• When a Whipple resection specimen is received, orient it
so that the stomach is on the left-hand side of the prosec-
tor and the duodenum is on the right-hand side (Fig. 5.11).
When positioned this way, the pancreatic resection mar-
gin will face the prosector.
• Probe the pancreatic duct from the visible pancreatic sur-
face. Ink this surface and submit it for frozen section eval-
uation (en face section) in one or two blocks.
48
Fig. 5.11  Pancreaticoduodenectomy (Whipple procedure) specimen.
The specimen consists of the pancreas, a portion of the stomach, and the
duodenum. The probes seen here are in the pancreatic duct and the
common bile duct. For frozen sections, the common bile duct and pan-
Fig. 5.12  Pancreaticoduodenectomy (Whipple procedure) specimen:
Vascular groove and retroperitoneal margin. The vascular groove is a
linear indentation that represents the area from which the superior mes-
• It can be helpful for the histotechnologist to know the
correct orientation of the section, so leave the probe in
the shaved pancreatic duct as it is placed on the frozen
chuck.
• Locate and ink the common bile duct margin. Shave and
submit this margin en face.
• To find the retroperitoneal resection margin (Fig.  5.12),
the prosector should take their left hand and place their
middle finger over the pancreatic resection margin, place
their index finger in the vascular groove, and place their
thumb on the other end of the pancreas. The area between
M. B. Lemos and M. Schwartz
creatic resection margins are submitted. For the latter, shave the entire
visible pancreatic surface and submit in one or two cassettes (en face
section)
enteric artery was dissected off by the surgeon. The retroperitoneal mar-
gin is adjacent to the vascular groove; it can be found using the
technique shown in Fig. 5.13
the prosector’s index finger and thumb is the retroperito-
neal margin (as shown in Fig. 5.13).
• Keep the specimen oriented as above (with the stomach
on the left and the duodenum on the right).
• Use a different color to ink the vascular groove, which is
near the retroperitoneal margin but appears slightly
depressed or concave.
• Sometimes the surgeon may request a frozen section of
the retroperitoneal margin. In this case, palpate the sur-
face and submit the area that is most firm (where the
tumor is closest to the margin).
5  Hepatobiliary and Pancreas
Fig. 5.13  Pancreaticoduodenectomy (Whipple procedure) specimen:
Finding the retroperitoneal margin. The vascular groove is a slightly
depressed linear indentation along the pancreas. To find the retroperito-
neal margin, place the left middle finger over the pancreatic resection
margin (see Fig.  5.11) and the left index finger along the vascular
Fig. 5.14  Pancreaticoduodenectomy (Whipple procedure) specimen:
Ampulla. After opening the duodenum and stomach, the ampulla is
probed. The ampulla is visible on the mucosal surface, and the probe
• Probe the ampulla and submit it as the first section (after
submission of margins) before grossing further (Fig. 5.14).
This helps to avoid the possibility of not being able to
locate the ampulla later after fixation and sectioning.
49
groove. The left thumb should be at the end of the pancreas opposite the
pancreatic resection margin. The retroperitoneal margin is between the
groove (index finger) and the end of the pancreas (thumb). The retro-
peritoneal margin, vascular groove, and pancreatic resection margin
should all be inked different colors
extends from the common bile duct throughthe ampulla. The ampulla
should be the first submitted section following frozen sections and
before further sectioning
• Open the pancreatic and common bile ducts, and ink their
opened edges each with a different color (Fig. 5.15). Ink
only the edges and avoid inking over the remainder of the
mucosa. Use the same colors used for the frozen sections
50 M. B. Lemos and M. Schwartz

Fig. 5.15 Pancreati­
coduodenectomy (Whipple
procedure) specimen: Opened
ducts. The pancreatic and
common bile ducts are
opened and inked at the
opened edges, marking each
with a different color. The
specimen can then be fixed in
formalin before further
sectioning

Fig. 5.16  Pancreaticoduodenectomy (Whipple procedure) specimen: surface and its relationship to adjacent ducts and the duodenum. If a
Sections. The pancreas is horizontally/transversely sectioned, and sec- tumor is not grossly identified, the entire pancreas should be submitted
tions are submitted sequentially. Note the presence of tumor on the cut

of the pancreatic resection and bile duct margins. After
inking, fix the specimen in formalin before taking further
sections.
• Transversely section the pancreas, including the attached
duodenal mucosa (Fig. 5.16).
• Next, examine the sections for tumor (Fig. 5.17). Submit
sections sequentially and in an order that will help keep
track of the size, location, and extent of the tumor
(Fig. 5.18).
• Take sections of the gastric margin and duodenal margin.
• Take representative sections of the stomach and duode-
num that are uninvolved by the tumor.
• Look for lymph nodes present in the peripancreatic fat.
Sample Dictation: Whipple Resection
Received fresh labeled as “Whipple” is a Whipple resection
specimen consisting of stomach (____ cm in length × ____ cm
in circumference), duodenum (____ cm in length × ____ cm in
circumference), and pancreatic head (____ × ____ × ____ cm).
The pancreas is serially sectioned and shows a ____ cm
mass obstructing the pancreatic duct (or the pancreatic duct
is patent). The common bile duct is patent (or there is a
____ cm tan-white area of induration). The mass is ____ cm
from the pancreatic resection margin and involves/does not
involve the ampulla. The bile duct is dilated/not dilated with
an adjacent ____ cm tan-pink lymph node.
5  Hepatobiliary and Pancreas 51

Fig. 5.17  Pancreaticoduodenectomy (Whipple procedure) specimen: Slice. This slice from a Whipple resection shows a close-up view of both the
tumor and the normal pancreas. Also note the common bile duct and pancreatic duct

Fig. 5.18  Pancreaticoduodenectomy (Whipple procedure) specimen: both cases, care is taken to submit sections in such a way that the size,
Submitting sections. The slice on the left is partially submitted (repre- location, and extent of a tumor or any lesion can be reconstructed later.
sentative sections). The slice on the right is completely submitted. In It should be similar to putting together pieces of a puzzle

The mucosa of the duodenum is tan-pink with normal Ink code:

folds. The gastric mucosa is tan-pink and unremarkable.
Identified are ___ # periduodenal lymph nodes ranging from • Violet – Retroperitoneal margin
____ to ____ cm. Also identified are ___ # lymph nodes in the • Blue – Common bile duct margin
adipose tissue adjacent to the pancreas measuring ____ cm. • Black – Pancreatic resection margin
Gross photographs are obtained. • Green – Vascular groove
52 M. B. Lemos and M. Schwartz

Section code: ∗The pancreatic resection margin and common bile duct
margin are typically submitted at the time of frozen section.
• AFS 1∗ – Pancreatic resection margin
Thus in this sample dictation, “FS” is added to the section
• AFS 2∗ – Common bile duct margin
code to indicate that these sections were submitted for frozen
• A3 – Ampulla
section.
• A4–A10 – Mass, sequential sections
• A11–A14  – Peripancreatic lymph nodes (specify # in
each cassette) Distal Pancreatectomy
• A15–A19 – Periduodenal lymph nodes (specify # in each
cassette) A distal pancreatectomy specimen may also include the
• A20 – Duodenum margin spleen (Figs. 5.19 and 5.20).
• A21 – Duodenum, representative section
• A22 – Gastric margin
• A23 – Stomach, representative section

Fig. 5.19 Distal
pancreatectomy. The
specimen includes the distal
pancreas and spleen. The
pancreatic resection margin
should be inked and submitted
separately

Fig. 5.20  Distal pancreatectomy: Sections. The pancreas and spleen are transversely sectioned and laid out sequentially. In this picture, a tumor
is visible in the sections of the pancreas
5  Hepatobiliary and Pancreas
Fig. 5.21  Splenectomy. The intact spleen is weighed and measured,
and the capsule is examined for any lesions or surface disruptions.
Here, a scarred area is identified on an intact splenic capsule. The vas-
Sample Dictation: Distal Pancreatectomy
Received fresh/in formalin is a distal pancreatectomy and
splenectomy specimen, which consists of the tail of the pan-
creas (____  ×  ____  ×  ____  cm) and the spleen
(____ × ____ × ____ cm).
Sections through the soft/firm/cystic pancreas show an
area of fibrosis (or tumor) (____ × ____ cm) located ____ cm
from the resection margin. The lesion does/does not involve
the spleen.
The remainder of the pancreatic parenchyma is lobulated/
fibrotic. Sections of the spleen are unremarkable, without
gross lesions or masses. Several lymph nodes are identified
in the fat around the pancreas and the hilar area.
Ink code:
• Blue – Pancreatic resection margin
Section code:
• A1 – Pancreatic resection margin
• A2–A10 – Mass, submitted sequentially
• A11 – Uninvolved spleen, representative section
• A12 – Uninvolved pancreas, representative section
• A13–A15 – Peripancreatic lymph nodes
• A16–A20 – Hilar lymph nodes
53
cular margins at the splenic hilum are then submitted. Finally, serial
sections of the spleen are made and the cut surface is examined
Splenectomy
Weigh the spleen, and examine the splenic capsule; submit
the hilar vascular margins and serially section the spleen
(Fig. 5.21).
Suggested Reading
Saka B, Balci S, Basturk O, Bagci P, Postlewait LM, Maithel S, et al.
Pancreatic ductal adenocarcinoma is spread to the peripancreatic
soft tissue in the majority of resected cases, rendering the AJCC
T-stage protocol (7th edition) inapplicable and insignificant: a size-­
based staging system (pT1: ≤2, pT2: >2-≤4, pT3: >4 cm) is more
valid and clinically relevant. Ann Surg Oncol. 2016;23:2010–8.
https://doi.org/10.1245/s10434-016-5093-7.
Soer E, Lodewijk B, Van de Vijver M, Dijk F, Van Velthuysen ML,
Farina-Sarasqueta AF, et  al. Dilemmas for the pathologist in
the oncologic assessment of pancreatoduodenectomy speci-
mens. Virchows Arch. 2018;472:533–43. https://doi.org/10.1007/
s00428-018-2321-5.
Verbeke CS, Gladhaug IP. Resection margin involvement and tumour
origin in pancreatic head cancer. Br J Surg. 2012;99:1036–49.
https://doi.org/10.1002/bjs.8734.
Verbeke CS.  Operative specimen handling and evaluation of resec-
tion margins. In: Kim SW, Yamaue H, editors. Pancreatic can-
cer: with special focus on topical issues and surgical techniques.
Berlin, Heidelberg: Springer; 2017. p.  67–88. https://doi.
org/10.1007/978-3-662-47181-4_5.
 Genitourinary
Monica B. Lemos and Steven Shen
Of the various types of genitourinary specimens, nephrec-
tomy specimens are some of the most common. Nephrectomy
specimens may include the entire kidney (radical nephrec-
tomy) or only a portion of the kidney (partial nephrectomy).
Total nephrectomy specimens may be received for removal
of a neoplasm or a non-neoplastic condition. A partial
nephrectomy is typically performed to remove a mass lesion
and includes the mass and a small amount of non-neoplastic
kidney tissue. Depending on the size and location of the
tumor, a partial nephrectomy may be preferred, as this tech-
nique allows for the preservation of kidney function and low-
ers the risk of subsequent chronic kidney disease.
Other types of genitourinary specimens include bladder
resections (cystectomy) and removal of the testis and sper-
matic cord (orchiectomy). In male patients, the bladder may
be received with the prostate (cystoprostatectomy). This
chapter discusses the proper handling of all of these
specimens.
Radical Nephrectomy
Grossing Tips: Nephrectomy
• First, find the ureter margin. Ink and submit this margin,
and then open the ureter.
• The lower pole is identified as the pole toward which the
ureter points as it leaves the hilum (Fig. 6.1).
• Find and submit the vascular margins. These are usually
stapled or clipped (Fig. 6.2).
M. B. Lemos (*)
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
e-mail: MBLemos@houstonmethodist.org
S. Shen
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
© Springer Nature Switzerland AG 2019
M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_6
6
• If the vascular margins are not easily visible, pull up the
area with staples and make a deep en face section. It
should be possible to cut through and remove all the mar-
gins with this technique.
• Check the renal vein for tumor involvement.
• Ink the outside surface of the kidney closest to where the
mass is palpated.
• Bivalve the kidney (Fig. 6.3).
• Describe the location of the tumor with respect to the kid-
ney poles (upper, mid, or lower).
• Take a parallel section to look for involvement of the
renal sinus by the tumor (Fig.  6.4). Make this section
very thin, so representative sections can be placed in a
cassette.
• Include a section of the tumor with the renal sinus, if the
tumor is close enough to the renal sinus area (Fig. 6.5).
• Include sections of any areas where perirenal fat or capsu-
lar invasion is suspected.
• Include a section of the tumor with adjacent normal kid-
ney parenchyma.
• After taking a parallel section, take perpendicular
sections to complete the gross evaluation and assess
for tumor invasion of the capsule or perirenal fat
(Fig. 6.6).
• Nephrectomy specimens may be received in cases of
polycystic kidney disease. In such cases numerous vari-
able sized cysts are typically present. It is important to
also look for any possible tumors that may also be present
(Fig. 6.7).
• Make sure to assess whether an adrenal gland is present in
the fat adjacent to the upper pole. Sometimes, only a rim
of adrenal is present, so look carefully to ensure it is not
missed. Measure and submit any adrenal tissue that is
present.
55
56 M. B. Lemos and S. Shen

Fig. 6.1 Radical
nephroureterectomy:
Orientation. Use the ureter as
a guide in identifying the
upper and lower poles of the
kidney. The ureter travels
downward, away from the
upper pole and toward the
direction of the lower pole.
The vascular margins are
found in the area where the
ureter inserts into the kidney
and the renal pelvis. These
margins are often stapled or
sutured. (See Fig. 6.2.)

Fig. 6.2  Radical nephroureterectomy: Margins. The ureter and vascu- vascular margins. If only a short segment of the ureter is excised, the
lar margins should be located and submitted before dissection of the ureter margin should still be located in the hilar area where the vessels
kidney. There is usually a staple line or clip, which helps to identify the are also clipped or stapled
6 Genitourinary 57

Fig. 6.3  Radical nephrectomy: Bivalved surface. After bivalving the ible. Because invasion into the perirenal fat, hilum, or renal sinus
kidney along the longitudinal axis, the relationship of the tumor with upstages the tumor, an accurate gross examination is critical
respect to the kidney poles, perirenal fat, renal pelvis, and hilum is vis-

Fig. 6.4 Radical
nephrectomy: Parallel
sectioning. After bivalving the
kidney, a parallel section will
help in further examining the
critical relationship of the
tumor to the hilar fat, renal
sinus, renal pelvis, and
perirenal tissue

Sample Dictation: Radical Nephrectomy
Received fresh/in formalin is a right/left nephrectomy speci-
men with perirenal fat and adrenal gland. The kidney is
___ × ____ × ____ cm and weighs ____ grams, and the adre-
nal gland is ____  ×  ____  ×  ____  cm. Extending from the
renal pelvis is a ureter measuring ____  cm in length and
____ cm in diameter.
The specimen is bivalved, and the cut surface reveals a
____  ×  ____  ×  ____  cm mass located in the upper/mid/
lower pole with a heterogeneous golden yellow and
focally hemorrhagic cut surface. The tumor is ____  cm
from the renal pelvis. The tumor pushes against the renal
capsule and appears to invade/not invade the capsule/peri-
renal fat. The tumor protrudes into the renal vein and is
____ cm from the renal vein margin. The remainder of the
renal cortex is red-brown with a well-defined cortical
­medullary junction. The pelvis and calyces are covered by
smooth, glistening mucosa. The adrenal gland/rim of the
adrenal gland is yellow-brown and grossly unremarkable.
58 M. B. Lemos and S. Shen

Fig. 6.5  Hilar invasion.

Pictured is a tumor with
obvious gross hilar invasion

Fig. 6.6 Radical
nephrectomy: Perpendicular
sectioning. After taking a
parallel section and
examining the relationship of
the tumor to the renal sinus
and hilum, take perpendicular
sections to completely
examine the relationship of
the tumor to the kidney
capsule and perirenal fat

The perirenal adipose tissue is serially sectioned, and __#

of lymph nodes are identified/no lymph nodes are
identified.∗

Section code:
• A1 – Ureter margin
• A2 – Vascular margins
• A3–A4 – Renal sinus/hilar region, in parallel sections
• A5 – Tumor with renal capsule and/or perirenal fat, paral-
lel section
• A6–A15 – Tumor, representative sections, perpendicular
• A16–A18  – Normal kidney parenchyma, representative
sections
• A19 – Renal fat, representative sections (or lymph nodes)

∗Note that most times, no lymph nodes are found. When

lymph nodes are present in the fat, they are most often found
Fig. 6.7  Polycystic kidney. A radical nephrectomy has been performed in the hilar area.
to remove a polycystic kidney, which also happens to have a tumor
6 Genitourinary 59

Sample Dictation: Polycystic Kidney gin. The attached perirenal fat contains/does not contain __#
of lymph nodes.
Received fresh and labeled as “____” is a kidney Gross photographs are taken.
(____ × ____ × ____ cm, weight _____ g) with attached Ink code:
perirenalfat. The specimen has a multinodular surface. The
renal capsule is intact, and a ureter is present, measuring • Blue – Surgical margin
____ cm in length and ___ cm in diameter. The renal artery
and renal vein are identified in the hilum. Section code:
The renal parenchyma is completely replaced by multiple • A1 – Ureter margin
cortical and medullary cysts measuring from ____  cm to • A2 – Vascular margins
____ cm in greatest dimension. The majority of the cysts are • A3–A4 – Renal sinus; hilum
filled with clear to brown fluid. The inner lining of the cysts • A5–A9 – Tumor, representative sections
is tan-red and smooth. The cysts are separated by tan fibrous • A10–A18 – Cysts, representative sections with adjacent
tissue with no/a small amount of normal renal parenchyma normal parenchyma
grossly noted. No papillary or mass lesions are noted (or) a
tumor is present within the upper/lower pole and measures
____  ×  ____  ×  ____  cm and is located ____  cm from the Partial Nephrectomy
hilum and invades/does not invade the hilar fat, renal sinus,
renal pelvis, and/or perirenal fat. The renal vein is patent Attention to orientation and inking of the entire resection
and shows no evidence of thrombosis/is invaded/is not margin should precede sequential sectioning of a partial
invaded by the tumor located ____ cm from the ureter mar- nephrectomy specimen (Figs. 6.8 and 6.9).

Fig. 6.8  Partial nephrectomy: Orientation. On the left is the smooth kidney capsular surface; on the right is the rough-appearing kidney parenchy-
mal resection margin. The resection margin should be inked entirely before sectioning the specimen
60
Fig. 6.9  Partial nephrectomy: Sectioning. Sequential perpendicular sections of the specimen are made to demonstrate the relationship of the
tumor to the inked parenchymal margin. Be sure to identify and submit the tumor closest to the inked resection margin
Cystectomy
Grossing Tips: Cystectomy
• To orient properly, think of the anterior surface of the
bladder as a rough, large abdomen, whereas the posterior
surface is like a smooth, flat back (Fig. 6.10).
• Ink the bladder using four colors for anterior, posterior,
left, and right (Fig. 6.11).
• For bladders received from female patients, extend the ink
to cover the urethra, then shave the urethral margin before
proceeding to open the bladder.
• Cut the bladder open with a “Y”-shaped incision from the
base to the dome (Fig. 6.12).
• Find the “bladder mouth,” and the dimples will be where
the ureteral orifices are. When probing, direct the probe
horizontally and almost parallel to the bladder mucosa
surface.
• Keep the probes in the ureters, then fix the opened bladder
overnight.
• While serially sectioning the bladder, mark slices with a
tumor or other abnormalities with a broken wooden stick.
M. B. Lemos and S. Shen
This will make it easy to keep track of which areas are
abnormal and should be submitted (Fig. 6.13).
• Submit full-thickness sections in areas with a tumor so
that microscopic tumor extension can be properly
assessed.
• If a prostate is present (cystoprostatectomy), the prostate
is typically removed with the seminal vesicles and
grossed separately. (In our institution, this is done by a
specifically designated Pathologist Assistant who only
grosses prostates.) Figure 6.14 however shows an image
of a cystoprostatectomy specimen with both bladder and
prostate
Sample Dictation: Cystectomy
Received is a cystectomy specimen that consists of urinary
bladder (____ × ____ × ____ cm), and attached adipose tis-
sue (____ × ____ × ____ cm).
There is an ulcerated/fungating/papillary mass
(____ × ____ × ____ cm) present in the right/left bladder
wall/trigone/dome. Grossly, the mass appears to invade
6 Genitourinary 61

Fig. 6.10 Cystectomy:
Orientation. The anterior
surface of the cystectomy
specimen is rough, and bulges
like a large abdomen. The
posterior surface is smooth
and flat like a back

Fig. 6.11  Cystectomy: Inking. The anterior and posterior surfaces are inked different colors. In addition, the right and left sides of the specimen
are inked with two different colors

into the bladder muscularis propria without extension into
the fat. [The prosector should also mention if the tumor
involves any of the inked outer margins.] There is a
____  ×  ____  cm erythematous/fibrotic mucosal area
located in the right/left bladder wall/trigone/dome. The
left and right ureteral orifices do not show involvement of
the tumor.
There is a ____ × ____ × ____ cm diverticulum located in
the left lateral bladder wall. No involvement of the tumor or
other mucosal abnormality is seen in the diverticulum.
62
Fig. 6.12  Cystectomy: Opening. Cut the bladder open from inferior to
superior using a “Y”-shaped incision. After opening, it should resemble
this picture. The ureter orifices may be difficult to identify on the muco-
sal surface; to aid in finding them, locate the ridge between the two
Fig. 6.13 Cystectomy: Sectioning. Serially section the bladder
sequentially from superior to inferior. Submit sections to show the
depth of invasion of the tumor and to include any abnormal areas (scar-
ring or erythema) that were seen on the mucosal surface. While section-
ing, keep the probes in the right and left ureteral orifices in the serial
M. B. Lemos and S. Shen
ureters, which resembles lips. If these “lips” are found, the openings
should be the two “dimples” at either end (see “Bladder Face” in the
inset). Probe the ureters and allow the bladder to fix before sectioning
further
sections, in order to keep track of them so that it is easy to submit sec-
tions of the ureteral orifices. The ink placed on anterior, posterior, right,
and left portions of the bladder (see Fig. 6.11) will also help to keep
track of the location of any lesion seen on serial sections
6 Genitourinary 63

Fig. 6.14 Cystopro­
statectomy with
verumontanum. In this
cystoprostatectomy specimen,
a tumor involves most of the
mucosal surface of the
bladder. The verumontanum
of the prostate is also visible

Ink code: • Take the spermatic cord margin first, before cutting into
the tumor (to avoid false positive margins due to tumor
• Blue – Anterior contamination).
• Black – Posterior • Bivalve the testis (Fig. 6.16).
• Yellow – Left • Note the size and appearance of the tumor on the cut sur-
• Red – Right face (Fig. 6.17).
• Take parallel sections to see the relationship of the
Section code: tumor to the capsule, normal testis parenchyma, and
epididymis.
• A1 – Urethral margin∗ • After parallel sections, take perpendicular sections.
• A2 – Right ureter, full-thickness
• A3 – Left ureter, full-thickness
• A4–A__ – Sequential full-thickness sections of tumor Sample Dictation: Orchiectomy
• A__–A__ – Erythematous mucosal area
• A__–A__  – Grossly uninvolved bladder, representative Received fresh/in formalin labeled as “_____” is a
sections right/left orchiectomy specimen consisting of testis
• A__–A__ – Dome, representative sections (____ × ____ × ____ cm), epididymis (____ × _____ × ____ cm),
and spermatic cord (____ cm length, ____ cm diameter).
∗Note: If the cystectomy is from a female, shave the ure- The testis is bivalved, and there is a ____ × ____ × ____ cm
thral margin tan-white firm, fleshy, well-circumscribed mass. Focal areas
of necrosis and hemorrhage are present. The tumor does not
grossly extend into the epididymis. The tumor extends
Orchiectomy ____ cm and closely abuts the tunica albuginea.
The remainder of the testicular parenchyma is tan and
Grossing Tips: Orchiectomy unremarkable. The tunica albuginea is tan-white, smooth,
and glistening. The epididymis is unremarkable. The sper-
• Ink the testis and spermatic cord margin different colors matic cord consists of vas deferens, arteries, and veins, and is
(Fig. 6.15). grossly unremarkable.
64 M. B. Lemos and S. Shen

Fig. 6.15  Orchiectomy. This orchiectomy specimen includes the testis also inked a separate color; this margin is cut and submitted before
and spermatic cord, the surfaces of which are inked different colors. sectioning the testis further
Also note the position of the epididymis. The spermatic cord margin is

Fig. 6.16  Bivalved testis. The testis is bivalved to reveal a tumor

6 Genitourinary 65

Fig. 6.17  Testis cut surface

with tumor. Note the tumor,
which looks different than the
adjacent normal testis
parenchyma. Sections of the
tumor close to the normal
parenchyma, tunica albuginea,
epididymis, and spermatic
cord should be submitted

Ink code: Suggested Reading

• Blue – Spermatic cord resection margin
Section code:
• A1 – Spermatic cord margin
• A2 – Mid portion of spermatic cord
• A3–A8 – Tumor, representative sections
• A9–A15 – Tumor with adjacent normal parenchyma
• A16–A21 – Testis normal parenchyma and tunica, repre-
sentative sections
• A22–A24 – Epididymis
Compérat E, Varinot J, Moroch J, Eymerit-Morin C, Brimo F. A practi-
cal guide to bladder cancer pathology. Nat Rev Urol. 2018;15:143–
54. https://doi.org/10.1038/nrurol.2018.2.
Grignon DJ, Al-Ahmadie H, Algaba F, Amin MB, Compérat E, Dyrskjøt
L, et  al. Tumors of the urinary tract. In: Moch H, Humphrey P,
Ulbright T, Reuter V, editors. WHO classification of tumors of
the urinary system and male genital organs. Zurich: International
Agency for Research on Cancer (IARC); 2016. p. 77–133.
Kunath F, Schmidt S, Krabbe LM, Miernik A, Dahm P, Cleves A, et al.
Partial nephrectomy versus radical nephrectomy for clinical localised
renal masses. Cochrane Database Syst Rev. 2017;(5):CD012045.
https://doi.org/10.1002/14651858.CD012045.pub2.
Lopez-Beltran A, Bassi P, Pavone-Macaluso M, Monitroni R. Handing
and pathology reporting of specimens with carcinoma of the urinary
bladder, ureter and renal pelvis. Eur Urol. 2004;45:257–66. https://
doi.org/10.1016/j.eururo.2003.09.018.
Moch H, Amin MB, Argani P, Cheville J, Delahunt B, Martignoni G,
et  al. Tumors of the kidney. In: Moch H, Humphrey P, Ulbright
T, Reuter V, editors. WHO classification of tumors of the urinary
system and male genital organs. Zurich: International Agency for
Research on Cancer (IARC); 2016. p. 11–76.
 Female Reproductive Tract
Monica B. Lemos, Donna Coffey, and Michael Deavers
Gynecologic pathology specimens constitute a sizable per-
centage of the specimens received in the surgical pathology
grossing suite, as many non-neoplastic and neoplastic condi-
tions of the uterus, ovary, and fallopian tube may require sur-
gical management. Hysterectomy specimens are among the
most common gynecologic specimens received. The adnexa
(ovary, fallopian tubes and ligaments) may also be removed
at the same time, depending on the clinical scenario. There
are various types of hysterectomies. A total simple hysterec-
tomy, the most common type, includes the uterine corpus
and cervix. Total simple hysterectomy specimens are per-
formed for most endometrial cancers, as well as most non-­
cancerous lesions of the uterus. A supracervical hysterectomy
is less common and includes the uterine corpus only, without
the cervix. A radical hysterectomy includes the uterine cor-
pus, cervix, parametrium, and the upper portion of the vagina
(vaginal cuff). This procedure is typically performed for pri-
mary cervical carcinoma or endometrial carcinomas that
extensively involve the cervix or that are centered in the
lower uterine segment.
Other common gynecologic specimens include cervical
excisions for cervical dysplasia or carcinoma, using a loop
electrosurgical excision procedure (LEEP) or cold knife
cone biopsy. Handling of oophorectomy and vulvectomy
specimens will also be discussed. This chapter discusses the
proper handling of commonly received gynecologic speci-
mens, and addresses clinical situations that require addi-
tional specimen sampling.
M. B. Lemos (*) · M. Deavers
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
e-mail: MBLemos@houstonmethodist.org
D. Coffey
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
© Springer Nature Switzerland AG 2019
M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_7
7
Hysterectomy
Grossing Tips: Hysterectomy
• Check the patient history found on the provided requisi-
tion or in the patient’s chart.
• Ink the anterior and posterior surfaces different colors
(Figs. 7.1 and 7.2).
• Weigh the specimen and adnexa (if included). Detach the
adnexa but keep track of which is anterior and which is
posterior.
• Before bivalving the uterus along the lateral uterine walls
(3 and 9 o’clock), shave the posterior cul-de-sac serosa
(which corresponds to the serosal “tail”), serially section
it, and submit it on-edge in the cassette (Fig. 7.3).
• Take measurements of the opened endometrial cavity and
any gross lesions (Figs. 7.4, 7.5 and 7.6).
• Take a vertical/longitudinal section of the lower uterine
segment and cervix first.
• Horizontally (transversely) section each half of the
bivalved uterus into thin slices from the fundus to the
lower uterine segment (Fig. 7.7).
• For uteri with endometrial carcinoma, measure the deep-
est point of myometrial invasion (Fig. 7.8).
• Measure the myometrial thickness. A trabeculated myo-
metrial cut surface may indicate adenomyosis.
• For endometrial tumors, submit representative sections
(at least one section per centimeter of tumor), to include
full thickness sections at the deepest point of invasion
(Figs. 7.9, 7.10 and 7.11).
• If the cervix is grossly involved with carcinoma, submit at
least two representative sections of tumor involving the
cervix. It is important that the sections of the cervix
include the full thickness of the cervical wall and the ecto-
cervical or vaginal cuff margin.
• In cases where the endometrial carcinoma extensively
involves the cervix, a radical hysterectomy may be per-
formed. In such cases, parametrial tissue can be found at
67
68 M. B. Lemos et al.

Fig. 7.1  Hysterectomy: Anterior. The smooth serosal surface extends aspects are identified, one can infer the laterality of attached adnexa.
lower posteriorly than it does anteriorly. This allows distinction between (Imagine the specimen in the patient either lying towards the prosector
the anterior and posterior uterine surfaces. Once anterior and posterior or facing away from the prosector.)

Fig. 7.2  Hysterectomy: Posterior. The serosal surface extends lower posteriorly, forming a “tail” towards the cervix
7  Female Reproductive Tract 69

Fig. 7.3  Hysterectomy: Anterior and posterior. This side-by-side picture of both anterior and posterior aspects of a uterus shows the greater infe-
rior extent of the smooth serosal surface on the posterior side

Fig. 7.4  Hysterectomy: Bivalved. The uterus is sectioned along the tening, unremarkable endometrial lining. (Compare with the endome-
lateral uterine walls (3 and 9 o’clock). Sectioning this way will provide trium involved by a tumor in Figs. 7.9 and 7.10.) There is a leiomyoma
the best visualization of the endometrial cavity, lower uterine segment, in the superior myometrium
and endocervix. The endometrial cavity here is lined by a smooth, glis-
70 M. B. Lemos et al.

Fig. 7.5 Supracervical
hysterectomy. This uterus has
been resected above the
cervix; only a stump is
present in the cervical area.
The uterus is markedly
distorted by multiple large
leiomyomas

Fig. 7.6  Submucosal leiomyoma. Many nodules can be seen in this bisected uterus, including submucosal leiomyomas located immediately
beneath the endometrial lining
7  Female Reproductive Tract 71

Fig. 7.7  Hysterectomy: Serial sectioning and intramural leiomyomas. be subserosal (located immediately beneath the serosal surface towards
Serial sections of the uterus are taken horizontally (transversely) from the outer aspect of the uterus). It is important to document any possible
the superior aspect to the inferior. The myometrium in these sections is areas of necrosis or hemorrhage in a suspected smooth muscle
remarkable for several intramural leiomyomas. Leiomyomas can also neoplasm

Fig. 7.8  Hysterectomy with polyp. Two polyps can be seen in this hys- is bivalved (left image). An endometrial polyp is also present within the
terectomy specimen. A cervical polyp is present within the endocervi- endometrial cavity superiorly (right image). Also, note a submucosal
cal canal and can be seen protruding from the cervix before the uterus leiomyoma (right image)
72 M. B. Lemos et al.

Fig. 7.9  Endometrial carcinoma. A mass can be seen filling the entire endometrial cavity. The lower uterine segment and cervix appear grossly
uninvolved, but representative sections should always be taken to rule out microscopic involvement by the tumor

Fig. 7.10 Endometrial
carcinoma: Lower uterine
segment section. This figure
demonstrates a longitudinal
section of the lower uterine
segment. Similar longitudinal
sections of the cervix should
also always be taken. Take
these sections first before
serially sectioning (Fig. 7.11),
so as not to forget or
inadvertently section through
the lower uterine segment and
cervix before such sections
can be taken

the lateral aspects of the cervix (3 o’clock and 9 o’clock),
along with the vaginal cuff. Radical hysterectomy
­specimens are typically performed in cases of primary
cervical carcinoma.
• If parametrium is present, measure the size of the parame-
trial tissue on each lateral aspect of the cervix. The para-
metrial margins should be inked. If a tumor is near the
parametrium, take sections to include the cervix, parame-
trium, and parametrial margin.
• If the tumor does not appear to involve the parametria, the
sections may include cervix, parametrium, and parame-
trial margins contiguously (as described above), or the
parametrial margins may be taken en face (depending on
the amount of parametrial tissue present), and the remain-
der of the parametrium may be submitted entirely in a
sequential manner, from lateral to medial.
• If a vaginal cuff is present, ink the cut surface of each
quadrant a different color (1 to 3 o’clock, 3 to 6 o’clock,
7  Female Reproductive Tract
Fig. 7.11  Hysterectomy with carcinoma: Sectioning. Each anterior and posterior half of the uterus is serially sectioned from the fundus to the
cervix in order to examine the depth of invasion of the tumor or any other lesions within the myometrium
6 to 9 o’clock, and 9 to 12 o’clock) (Fig. 7.12). Shave off
each quadrant and submit each in a cassette ink-side
down, or place on a chuck ink-side up if a frozen section
is requested.
• In benign uteri, or those with carcinoma of a non-serous
histotype, representative sections of the fallopian tube, to
include the entire fimbriated end (longitudinally sec-
tioned), and representative cross-sections of the remain-
der of the tube should be submitted. In cases of uterine
serous carcinoma, the SEE-FIM protocol should be per-
formed (see Fig. 7.19).
• The ovaries, if present, should be serially sectioned along
the long axis. Submit sections of any abnormal nodules or
lesions. In benign uteri and endometrial carcinoma of a
non-serous histotype, representative sections will suffice.
In cases of uterine serous carcinoma, the entire ovary
should be submitted.
Sample Dictation: Hysterectomy
Received fresh labeled as “_____” is a total hysterectomy
specimen/supracervical hysterectomy specimen/hysterec-
tomy specimen with an amputated cervix (_____  grams,
____ × ____ × ____ cm) with attached bilateral adnexa (right
ovary ____ × ____ × ____ cm, right fallopian tube ____ cm
73
in length and ____  cm in diameter, left ovary
____ × ____ × ____ cm, left fallopian tube ____ cm in length
and ____ cm in diameter).
The uterine serosal surface is tan-pink and smooth (or)
has tan-white areas of granularity (____ cm). The ectocervix
is white-gray smooth and glistening with a ____ cm cervical
os/slit-like os. The endometrial cavity is ____ × ____ cm and
lined by a ____ cm tan-pink smooth and glistening endome-
trium (or) the endometrial cavity is replaced/partially
replaced by a ____ × ____ × ____ cm tan-pink friable mass,
infiltrating __ cm into a ___ cm thick myometrium. Attached
to the fundus in the posterior/anterior aspect is a ____  cm
tan-pink polyp.
The myometrium is tan-pink and rubbery/trabeculated
and is ____  cm in thickness. Multiple tan-white whorled
intramural/submucosal/subserosal nodules are present.
The cut surfaces of the nodules are grossly unremarkable
without hemorrhage or necrotic areas. The surface of the
right ovary is yellow-tan and convoluted/tan-pink and
smooth. The cut surface shows corpora albicantia ranging
from ____  cm to ____  cm. There are also multiple cysts
filled with clear fluid/seromucinous fluid and ranging from
____  cm to ____  cm. The surface of the right fallopian
tube is tan-pink and smooth with paratubal cysts present
ranging from ____  cm to ____  cm and filled with clear
fluid.
74 M. B. Lemos et al.

Fig. 7.12  Vaginal cuff. Some hysterectomy specimens may be received
with a vaginal cuff (typically received as part of a radical hysterectomy
specimen, indicated for some cervical carcinomas). The vaginal cuff
margins may also need to be assessed intraoperatively in the frozen sec-
tion suite. In this case, the left and right edges of the margin are inked
different colors (in this figure, blue and black, respectively). Single dots
of different colored ink are placed at intervals indicating clock position
around the margin for greater accuracy. The margin is shaved and sub-
mitted from each dot to the next. A diagram (shown to the right) can be
drawn as a legend of the ink colors used for each section submitted

Ink code: • A___–A___ – Left ovary

• A___–A___ – Left fallopian tube
• Blue – Anterior
• Black – Posterior
Oophorectomy and Salpingectomy
Section code:
Ovary and fallopian tube specimens require the use of some
• A1 – Anterior cervix specific procedures. For ovarian specimens with mass
• A2 – Posterior cervix lesions, the outer surface of the ovary should be inked before
• A3 – Posterior cul-de-sac serosa sectioning. (Figs. 7.13, 7.14, 7.15, 7.16, 7.17, 7.18 and 7.19).
• A4–A7 – Endometrium and myometrium, anterior aspect,
representative sections from fundus to lower uterine
segment Sample Dictation: Cystic Ovary
• A8–A11  – Endometrium and myometrium, posterior
aspect, representative sections from fundus to lower uter- Received fresh and labeled as “_____” is an intact/previ-
ine segment ously opened cystic ovary (____  grams,
• A12–A14 – Representative sections of intramural nodules ____ × ____ × ____ cm). The surface of the specimen is tan-­
(for nodules 5 cm or larger, take one section per cm) white to pink and smooth (or with nodules or papillary
• A15–A___ – Right ovary excrescences present).
• A___–A___ – Right fallopian tube
7  Female Reproductive Tract 75

Fig. 7.13  Cystic ovary. This ovary is almost completely replaced by a

cystic lesion. Notice the fallopian tube attached to the cystic ovary. The
presence of the fallopian tube should be noted; detach it before opening
the cyst

Fig. 7.14  Cystic ovary: Inner lining and papillary excrescences. Seen and sections of such areas submitted. Any solid areas should also be
here is the inner lining of an opened ovarian cyst. This inner surface noted and sections submitted
should be carefully evaluated for papillary excrescences (right image)
76 M. B. Lemos et al.

Fig. 7.15  Cyst roll. The advantage of submitting an ovarian cyst as a
roll is that it maximizes visualization of the greatest surface area of the
cyst per section submitted. This technique can be used to submit ovar-
ian cysts for frozen (left) as well as permanent (right) sections. The
disadvantage is that in some cases, this technique may distort the epi-
thelial lining of the cyst, and thus may hinder microscopic interpreta-
tion. Therefore, submitting in this manner will depend on the preference
of the pathologist. An alternative method of sectioning a cystic ovary
includes submitting longitudinal strips of cyst wall placed in the cas-
sette on edge

Fig. 7.16  Cystic teratoma.

This ovarian cyst includes a
solid tumor component and a
cystic component with hair,
representing a mature
teratoma. Various elements,
including teeth and bone, can
also be present in teratomas.
Solid portions or any areas
that look different should be
sampled in such cystic ovary
specimens
7  Female Reproductive Tract 77

Fig. 7.17  Ovary: Sectioning. Shown are the intact ovary (left) and serial sections (right). Note the tan-white corpora albicantia seen on the cut
surface

Fig. 7.18  Ovary: Corpora lutea and albicantia. The cut surface of this ovary shows the corpus luteum (golden-yellow and cystic) as well as the
corpora albicantia (white-colored)
78
Fig. 7.19  Ovary and fallopian tube: SEE-FIM protocol (Sectioning
and Extensively Examining the FIMbriated End protocol). In patients
with BRCA mutations who have undergone prophylactic salpingo-­
oophorectomy, the fimbriated end of the fallopian tube is amputated at
the infundibulum (distal 2 cm of fallopian tube). The distal 2 cm of the
fallopian tube is sectioned parallel to the long axis of the tube and sub-
mitted entirely. Alternatively, the distal fimbriated end of the fallopian
Sectioning of the ovary reveals a ____  cm unilocular/
biloculated/multiloculated cyst(s) ranging from ____ to
____ cm in diameter and filled with yellow, clear, gelatinous
material (or gray-white paste-like material and hair, in a
mature cystic teratoma). The inner lining of the cyst is tan-­
pink and smooth (or tan-pink with papillary excrescences
measuring up to ____ cm). The thickness of the wall ranges
from ____ to ____ cm.
Ink code:
• Blue – Entire outer surface of ovary
Section code:
• A1–A10 – Representative sections of cyst wall
• A11–A13 – Papillary excrescences∗
∗Note: Always make sure to submit any areas of papillary
excrescences or solid areas.
Cervical Cone
Cone-shaped portions of cervix from cervical cone biopsies
are inked and radially sectioned (Figs. 7.20 and 7.21).
M. B. Lemos et al.
tube may first be opened with scissors, and then additional parallel sec-
tions may be made. The remainder of the fallopian tube is sectioned
horizontally (“bread loafed”) at intervals of 2–3  mm and submitted
entirely. In this image, the fallopian tube shows small paratubal cysts, a
very common finding. In these cases, the ovaries should be serially sec-
tioned at intervals of 2–3 mm along the long axis and submitted entirely
Sample Dictation: Cervical Cone
Received fresh labeled as “_____” is an oriented conical por-
tion of tissue. The endocervical margin is inked black, and
the ectocervical margin is inked blue. The specimen is radi-
ally sectioned, and the cut surface is pale-tan and rubbery/
slightly firm. The specimen is entirely submitted sequen-
tially from 1 to 12 o’clock in cassettes A1–A12.
Vulvectomy
When examining vulvectomy specimens, understanding the
proper orientation is the first crucial step. The specimen
should then be inked and subsequently sectioned (Figs. 7.22,
7.23 and 7.24).
Sample Dictation: Vulvectomy
Received labeled as “____” is an oriented/unoriented irregu-
lar piece of vulvar skin with underlying fibroadipose tissue
(____  ×  ____  ×  ____  cm). The surface of the specimen
reveals an ulcerated/nodular/discolored friable lesion
(___ × ___ cm), which is ____ cm from the closest margin
7  Female Reproductive Tract
Fig. 7.20  Cervical cone: Oriented specimen. The ectocervical margin
and endocervical margins should be identified and inked different col-
ors. The base of the specimen opposite the cervical opening is the endo-
cervical margin. The endocervical margin should be inked. The
periphery of tissue all around the specimen, excluding the surface ecto-
Fig. 7.21  Cervical cone: Radial sectioning. Each half of the bivalved
cone specimen should be sectioned radially. This should result in at
least 12 cassettes, one for each position (i.e., A1 = 1 o’clock, A2 = 2
79
cervical mucosa, includes the ectocervical and deep margins; these
margins should also be inked a different color. After the margins have
been inked, the specimen is bivalved horizontally along the lateral
aspect (3 and 9 o’clock), and sections are taken for each clock position
(see Fig. 7.21)
o’clock, A3  =  3 o’clock, and so on until A12). The cuts are made
towards the center of the cone (similar to sections of a pie)
80 M. B. Lemos et al.

Fig. 7.22  Vulvectomy. A

vulvectomy specimen is
shown, which is oriented by
the surgeon with sutures. Note
the lesion in the center, which
appears as a tan-white
discolored area

Fig. 7.23  Vulvectomy: Inking of margins. The margins are inked two placed at various o’clock positions, and the margins are shaved. A dia-
colors on both sides (including the peripheral edges and deep surface) gram is drawn to keep track of the colors used for each position
to indicate 12-3-6 o’clock and 6-9-12 o’clock positions. Then dots are
7  Female Reproductive Tract
Fig. 7.24  Larger vulvectomy specimen. Some vulvectomy specimens
include more extensive tissue resection. In such larger vulvectomy
specimens, a more selective strategy of sampling the margin can be
used. Ink the right and left parts different colors (including the periph-
eral edges and deep surface), but submit only the portion of the
margin(s) closest to the lesion for frozen section (if the specimen is
received in the frozen section suite). Then make perpendicular sections
to evaluate the deepest invasion of the lesion and submit the closest
deep margin. For permanent sections, the complete specimen may be
submitted, or only the remainder of the lesion with adjacent normal
tissue
(e.g., 3 o’clock margin, 6 o’clock margin, deep margin, etc.).
The remainder of the surface reveals multiple satellite
­nodules/pigmented lesions ranging from ____ to ____  cm
and located ____ cm from the closest margin(s).
The specimen is inked and serially sectioned sequentially
from medial to lateral (or) from 12 o’clock to 6 o’clock and
submitted entirely/representatively, sequentially from 12
o’clock to 6 o’clock or from medial to lateral in cassettes
A1–A12.
81
Ink code:
• Blue – Superior
• Orange – Inferior
or
• Blue – Medial
• Orange – Lateral
or
• Black – 12-3-6 o’clock
• Purple – 6-9-12 o’clock
Suggested Reading
Ismill N, Ghorab Z, Covens A, Nofech-Mozes S, Saad R, Khalifa
MA.  Intraoperative margin assessment of the radical trach-
electomy specimen. Gynecol Oncol. 2009;113:42–6. https://doi.
org/10.1016/j.ygyno.2008.12.025.
Koc N, Ayas S, Arinkan SA. Comparison of the classical method and
SEE-FIM protocol in detecting microscopic lesions in fallopian
tubes with gynecological lesions. J Pathol Transl Med. 2018;52:21–
7. https://doi.org/10.4132/jptm.2016.06.17.
Malpica A, Euscher ED, Hecht JL, Ali-Fehmi R, Quick CM, Singh
N, et  al. Endometrial carcinoma, grossing and processing issues:
recommendations of the International Society of Gynecologic
Pathologists. Int J Gynecol Pathol. 2019;38(Suppl 1):S9–24. https://
doi.org/10.1097/PGP.0000000000000552.
Medeiros F, Muto MG, Lee Y, Elvin JA, Callahan MJ, Feltmate C, et al.
The tubal fimbria is a preferred site for early adenocarcinoma in
women with familial ovarian cancer syndrome. Am J Surg Pathol.
2006;30:230–6.
 Lung
Monica B. Lemos and Roberto Barrios
Pulmonary specimens may be received in the surgical pathol-
ogy grossing suite as part of the clinical workup and man-
agement of both neoplastic and non-neoplastic conditions,
including infectious processes. Types of lung specimens
commonly encountered include lung biopsies, wedge resec-
tions, lobectomy specimens, and pneumonectomy speci-
mens. A lung wedge resection consists of removal of a
smaller portion of lung tissue; the parenchymal surgical mar-
gin of resection is typically stapled. A lobectomy specimen
consists of an entire lung lobe; in such specimens, the key
margin is the bronchial resection margin. A pneumonectomy
specimen consists of the entire lung, which may be received
for a variety of conditions, including neoplastic and non-­
neoplastic processes. In the case of malignancy, a pneumo-
nectomy, rather than a smaller resection, may be indicated
because of the location of a tumor. Pneumonectomy speci-
mens may also be encountered in practice settings with a
lung transplantation service. This chapter discusses the han-
dling of pneumonectomy specimens, lobectomy specimens,
and wedge resections.
Pneumonectomy
After identifying and submitting the bronchial and vascular
margins, the pneumonectomy specimen is serially sectioned
(Figs. 8.1, 8.2 and 8.3).
M. B. Lemos (*)
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
e-mail: MBLemos@houstonmethodist.org
R. Barrios
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
Weill Cornell Medicine, New York, NY, USA
© Springer Nature Switzerland AG 2019
M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_8
8
Lung Lobectomy and Wedge Resections
 rossing Tips: Lung Lobectomy and Wedge
G
Resections
• When the specimen is received, wear a mask, especially
in cases where tuberculosis infection is possible.
• Weigh the specimen and take bronchial and vascular mar-
gins first.
• Check for staple lines. Remove the staples and ink the
lung parenchyma beneath them (Figs. 8.4, 8.5 and 8.6).
• If received fresh in the frozen section pathology suite,
prepare touch preparation slides on lesions identified
(particularly in wedge resections).
• If granulomas are found on touch preparation, be sure to
wear a mask, because of the risk of tuberculosis. Frozen
sections will not likely be performed in this case, but if
they are, the cryostat should be promptly decontaminated
following any possible exposure.
Sample Dictation: Lung Lobectomy
Received fresh labeled as “____” is a right/left upper/mid-
dle/lower lobe (____ grams, ___ × ___ × ___ cm). The pleu-
ral surface is dark red and shows a ____ cm area of retraction
or a ____ cm firm area. The remainder of the pleural surface
is smooth and unremarkable. The specimen is serially sec-
tioned along the long axis and shows a white-gray, firm,
well-circumscribed mass ____ cm from the bronchial mar-
gin and ___ cm from the stapled margin. The remainder of
the parenchyma is red-pink with scattered black spots rang-
ing from 0.1 to 0.3 cm, suggestive of anthracosis.
83
84 M. B. Lemos and R. Barrios

Fig. 8.1  Left pneumonectomy. Two lobes (left upper and left lower) are identified in a left pneumonectomy specimen. The resected portions of
bronchus and vessels are seen in the hilar area; these represent margins and should be submitted first before sectioning the rest of the lung

Fig. 8.2  Right pneumonectomy. Three lobes (right upper, right middle, and right lower) are identified in a right pneumonectomy specimen. Again,
the hilar bronchial and vascular margins are identified and should be submitted first
8 Lung 85

Fig. 8.3  Pneumonectomy: Sections. The pneumonectomy is serially sectioned along the long axis, and the cut surface is examined for areas of
fibrosis, tumor, or other abnormalities. Note the areas of fibrosis seen in these sections

Fig. 8.4  Lung lobectomy. A lung lobe resection with a palpable subpleural tumor is pictured. The pleural surface overlying the tumor is inked.
Note that pleural invasion will affect the stage of malignant lung tumors
86 M. B. Lemos and R. Barrios

Fig. 8.5  Lung lobectomy: Bronchial and vascular margins. The bronchial and vascular margins in this lobectomy specimen are stapled (left
image). The staples are removed, and the lumen of the bronchus and vessel can be seen (right image)

Fig. 8.6  Lung wedge resection. A wedge resection typically includes a is visible and is protruding through the pleural surface. Serial sections
parenchymal margin, which should be inked and submitted. This resec- of the wedge are made. The tumor can be seen clearly in these sections,
tion margin is identified by the surgeon’s staples. In this wedge, a tumor which are laid out sequentially

Ink code: • A6–A__ – Tumor

• A__–A__ – Normal parenchyma
• Blue – Retraction (or firm area) of pleural surface
• Orange – Stapled margin

Section code: Suggested Reading

• A1 – Vascular margin Harrison S, Stiles B, Altorki N.  What is the role of wedge resection
• A2 – Bronchial margin for T1a lung cancer? J Thorac Dis. 2018;10(Suppl 10):S1157–62.
• A3–A5 – Hilar lymph nodes https://doi.org/10.21037/jtd.2018.03.188.
8 Lung
Lackey A, Donington JS.  Surgical management of lung cancer.
Semin Intervent Radiol. 2013;30:133–40. https://doi.org/10.105
5/s-0033-1342954.
Ritterhouse L, Sholl LM.  The molecular pathology of lung cancer:
pre-analytic considerations. In: Cagle PT, Allen TC, Beasley MB,
et al., editors. Precision molecular pathology of lung cancer. 2nd ed.
87
Cham: Springer International Publishing; 2018. p.  79–92. https://
doi.org/10.1007/978-3-319-62941-4.
Sienko A, Allen TC, Zander DS, Cagle PT.  Frozen section of lung
specimens. Arch Pathol Lab Med. 2005;129:1602–9. https://doi.
org/10.1043/1543-2165(2005)129[1602:FSOLS]2.0.CO;2.
 Bone and Soft Tissue
Monica B. Lemos and Michael Deavers
Acquiring competence in the gross examination of bone and
soft tissue specimens can be challenging, particularly as
these specimens are not common. Of the bone specimens
that are received in the surgical pathology grossing suite,
femoral head and knee arthroplasty specimens are among the
most frequent. Such specimens are typically received during
surgical procedures indicated for osteoarthritis. Other types
of bone and soft tissue specimens seen include amputations,
such as below-the-knee and above-the-knee amputations,
often due to gangrene. Bone resections for neoplastic condi-
tions are rare. In such cases, review of the pre-operative
radiographic imaging is essential. Furthermore, in certain
cases, tumor mapping may be required.
When performing gross examinations of bone specimens,
having appropriate cutting instruments and ensuring proper
fixation and adequate decalcification are very important.
Inadequate fixation and decalcification can both be problem-
atic and lead to suboptimal sections. This chapter illustrates
examples of various bone specimens and describes the
appropriate handling of such specimens.
Femoral Head
Thin sections made with a bone saw will include the overly-
ing cartilage and the cortex (Figs. 9.1 and 9.2).
Sample Dictation: Femoral Head
Received in formalin labeled as “right/left femoral head” is a
femoral head resection specimen (____ × ____ × ____ cm)
M. B. Lemos (*) · M. Deavers
Department of Pathology and Genomic Medicine, Houston
Methodist Hospital, Houston, TX, USA
e-mail: MBLemos@houstonmethodist.org
© Springer Nature Switzerland AG 2019
M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4_9
9
with a hemorrhagic and jagged margin of resection (for his-
tory of fracture). The articular surface varies from smooth to
focally scratched and pitted. The underlying bone is tan-­
yellow with hemorrhage at the margin. There is a ____ cm
tan, pale, wedge-shaped area with detached cartilage (for
cases of avascular necrosis). The cartilage thickness ranges
from ____ to ____ cm.
• A1–A3  – Representative sections following
decalcification
Knee Arthroplasty
Specimens obtained during knee arthroplasty are likely to
include both bone and soft tissue (Fig. 9.3).
Sample Dictation: Knee Arthroplasty
Received in formalin and labeled “right/left bone and tissue”
is a ____ × ____ × ____ cm aggregate of irregular to ovoid
portions of tan-yellow bone and gray-white cartilage, in
addition to soft tissue. Tibial plateau and femoral condyle
configurations are present. The bone is partially covered by
concave and convex articular surfaces. The articular surface
varies from smooth to pitted, nodular, and partially eroded.
There are focal areas of eburnation measuring up to ____ cm.
Osteophyte formation in the peripheral aspect is identified.
• A1–A2 – Representative sections of bone
• A3 – Soft tissue
89
90 M. B. Lemos and M. Deavers

Fig. 9.1  Femoral head. This femoral head resection specimen was removed during hip replacement surgery. A thin section is made with a bone
saw through the center of the femoral head, and sections are submitted as shown to include the overlying articular cartilage and cortex

Fig. 9.2  Avascular necrosis.

An area of avascular necrosis
is seen in this femoral head
resection specimen. The
lesion is tan, pale, and
wedge-shaped. Submitted
sections (right) include the
area of avascular necrosis and
detached cartilage
9  Bone and Soft Tissue
Fig. 9.3  Knee: Bone and tissue. These fragments of tissue from a knee arthroplasty show areas of eburnation and erosion, characteristic of osteo-
arthritis. Note the femoral condyle and tibial plateau portions of the specimen
Fig. 9.4  Bone tumor resection. The specimen should be oriented by
the surgeon, usually with sutures. The specimen is inked and oriented
with different colors. The bone margins should be taken, and then the
specimen should be bivalved (see Fig. 9.5)
Bone Tumor Resection
Bone tumor resection specimens should be oriented, inked,
bivalved, and subsequently mapped (Figs. 9.4, 9.5 and 9.6).
91
Amputations
Grossing Tips: Leg Amputation
• Measure the specimen.
• Check for lesions including ulcers and areas of gangrene.
Measure these lesions and their location with respect to
the resection margin (Figs. 9.7, 9.8 and 9.9).
• Ink the skin and soft tissue resection margins in the area
closest to any noted lesions (Fig. 9.10). Submit representa-
tive sections of skin and soft tissue at the resection margin.
• To assess the bone resection margin, a section of bone at
the margin may be taken, or the bone marrow at the mar-
gin may be scraped, and submitted in a biopsy bag.
Submitting a cut section of the bone resection margin is
preferable in cases of osteomyelitis.
• Locate the anterior tibial artery. This can either be found
at the resection margin, or it can be found by making a
transverse section on the anterior leg between the tibia
and fibula (Fig. 9.11).
• The artery can likely be found by probing with the finger.
• The posterior tibial artery can be found easily by palpat-
ing the soft tissue at the resection margin in a below-the-­
knee amputation. It is often calcified and can thus be
easily felt.
92 M. B. Lemos and M. Deavers

Fig. 9.5  Bone tumor

resection: Bivalved. The cut
halves of the bone tumor
resection show a tumor that
has eroded and replaced much
of the bone. There are two
bone resection margins, one at
each end of the portion of the
resected bone. These resection
margins should be inked and
submitted in two different
cassettes, which are
subsequently placed into
decalcification solution. Then
the main specimen should be
placed in formalin overnight
before further sectioning

Fig. 9.6  Bone tumor

resection: Mapping. A thin
slice is cut from each side of
the bivalved specimen (see
Fig. 9.5). The slices are then
mapped to show the location
of each submitted section.
After submitting each of the
sections, the cassettes are
placed into decalcification
solution before processing

Fig. 9.7 Above-the-knee amputation. This above-knee amputation

specimen includes the foot, lower leg, and knee
9  Bone and Soft Tissue 93

Fig. 9.8  Above-the-knee amputation: Lesions. Notice the difference

between normal skin, dry scaly skin, and a gangrenous area

Fig. 9.9  Gangrenous toe lesion. Note the black, hard, gangrenous area
on the great toe. There is also skin slippage on portions of the toes

Fig. 9.10  Above-knee amputation: Resection margins. The resection

margins include the soft tissue margin (skin, fat, and muscle) and the
bone resection margin

Fig. 9.11  Anterior tibial artery dissection. The anterior tibial artery has been dissected out and should be opened and assessed for calcification
and/or atherosclerotic stenosis
94
Fig. 9.12  Popliteal artery
dissection. The popliteal
artery is also dissected out
and opened to assess for
calcification or atherosclerosis
Fig. 9.13  Transmetatarsal amputation. Shown is a transmetatarsal
amputation of a gangrenous foot. The skin and soft tissue resection
margins closest to any noted lesion should be inked, and sections should
then be taken. The bone resection margin should also be inked and sub-
mitted, particularly in cases of osteomyelitis. Note the absence of the
fifth toe, which in this patient was previously amputated
• Similarly, the popliteal artery can be easily found by pal-
pation of the resection margin in an above-the-knee
amputation (Fig. 9.12).
• Mention the maximum percent stenosis by any calcifica-
tion or plaque in the vessels.
• When there is a history of osteomyelitis, submit a section
of bone underlying the lesion.
• In some cases, there has been a previous amputation, so
be sure to check for the presence of missing (previously
amputated) toes (Fig. 9.13).
M. B. Lemos and M. Deavers
Sample Dictation: Transmetatarsal
Amputation
Received in formalin, labeled “right/left transmetatarsal
amputation” is a ____  ×  ____  ×  ____  cm transmetatarsal
amputation specimen with five toes/previously amputated
____ toes. Tan-yellow unremarkable toenails are present.
There is a black ulcerated and gangrenous black lesion on
the dorsal/plantar surface/toe. The lesion is ____  cm from
the soft tissue resection margin.
Ink code:
• Blue – Soft tissue resection margin
• Black – Bone resection margin
Section code:
• A1 – Soft tissue resection margin
• A2 - A3 – Lesions (areas of gangrene, etc.)
• A3 – Anterior vessels
• A4 – Posterior vessels
• A5 – Normal skin
• A6 – Bone resection margin, following decalcification
• A7 – Representative sections of bone underlying lesions
(osteomyelitis), perpendicular, following decalcification
Suggested Reading
Dimenstein IB.  Bone grossing techniques: helpful hints and proce-
dures. Ann Diagn Pathol. 2008;12:191–8. https://doi.org/10.1016/j.
anndiagpath.2007.06.004.
Khurana JS, Arguello-Guerra V.  Grossing of bone and soft tis-
sue (common specimens and procedures). In: Khurana J, edi-
tor. Bone pathology. New  York: Humana Press; 2009. https://doi.
org/10.1007/978-1-59745-347-9_7.
Klein MJ, Memoli VA. Orthopaedic specimen preparation: what pathol-
ogists should know and do. Semin Diagn Pathol. 2011;28:4–12.
 Index

A Cholecystectomy
Amputations cystic duct margin, 46, 47
anterior tibial artery dissection, 91, 93 gallbladder, 46
gangrenous toe lesion, 91, 93 sample dictation, 46, 47
lesions, 91, 93 sectioning, 47
popliteal artery dissection, 94 sections, 46
resection margins, 93 specimen, 46
specimen, 91, 92 Cystectomy
transmetatarsal amputation, 94 inking, 60, 61
Appendectomy, 39, 40 opening, 60, 62
Appendix, 38–40 orientation, 60, 61
Axillary lymph node sampling, 5 sample dictation, 60, 61, 63
sectioning, 60
Cystoprostatectomy, 60, 63
B
Bone and soft tissue
amputations D
lesions, 91, 93 Distal pancreatectomy
anterior tibial artery dissection, 91, 93 distal pancreas and spleen, 52
gangrenous toe lesion, 91, 93 pancreas and spleen, 52
popliteal artery dissection, 94 sample dictation, 53
resection margins, 93 sections, 52
specimen, 91, 92 spleen, 52
transmetatarsal amputation, 94
femoral head
avascular necrosis, 89, 90 E
resection, 89, 90 Esophagogastrectomy
sample dictation, 89 esophagectomy, 27, 29
knee arthroplasty, 89, 91 esophagus, 28
Bone tumor resection gastrectomy, 27
bivalved, 92 stomach, 28
mapping, 92
specimen, 91
Breast F
axillary lymph node sampling, 5 Female reproductive tract
cancer diagnosis, 5 cervical cone
lumpectomy (see Lumpectomy) oriented specimen, 78, 79
mastectomy (see Mastectomy) radial sectioning, 78, 79
sentinel lymph nodes, 11, 12 sample dictation, 78
Breast-conserving therapy, 5 hysterectomy (see Hysterectomy)
oophorectomy (see Oophorectomy)
salpingectomy, 74, 78
C vulvectomy
Cervical cone inking of margins, 78, 80
oriented specimen, 78, 79 larger vulvectomy specimen, 78, 81
radial sectioning, 78, 79 sample dictation, 78, 81
sample dictation, 78 specimen, 78, 80
Follicular carcinomas, 18

© Springer Nature Switzerland AG 2019 95

M. B. Lemos, E. Okoye (eds.), Atlas of Surgical Pathology Grossing, Atlas of Anatomic Pathology,
https://doi.org/10.1007/978-3-030-20839-4
96 Index

G sectioning, 67, 73
Gastrointestinal tract serial sectioning and intramural leiomyomas, 67, 71
appendectomy, 39, 40 submucosal leiomyoma, 67, 70
esophagogastrectomy supracervical, 67, 70
esophagectomy, 27, 29 total simple hysterectomy, 67
esophagus, 27, 28 vaginal cuff, 72, 74
gastrectomy, 27
stomach, 27, 28
ileostomy, 29 I
ostomy site, 29 Ileocolectomy, 38
sample dictation, 29 Ileostomy, 29
sectioning, 30 ostomy site, 29
large bowel (see Large bowel) sample dictation, 29
polypectomy, 40 sectioning, 30
routine specimens, 27
small bowel
inking, 31 L
Meckel’s diverticulum, 30, 31 Large bowel
subserosal tumor resection, 31 with adhesed ovary, 37, 38
subserosal tumor sectioning, 31 colon tumor
Genitourinary depth of invasion, 30, 34
cystectomy longitudinal sectioning, 30, 33
inking, 60, 61 colon with Crohn’s disease, 34, 36, 37
opening, 60, 62 colon with ulcerative colitis, 34, 36
orientation, 60, 61 diverticulitis, 35
sample dictation, 60, 61, 63 adhesions, 34, 35
sectioning, 60, 62 mucosal surface, 34, 35
cystoprostatectomy, 60 sections, 34, 36
nephrectomy (see Nephrectomy) low anterior resection, 38, 39
orchiectomy rectum
bivalved testis, 63, 64 with anal mucosa and dentate line, 30, 34
sample dictation, 63, 65 radial margin, 30, 33
testis and spermatic cord margin, 63, 64 right hemicolectomy
testis cut surface with tumor, 63, 65 ileum, cecum, and right colon, 30, 32
Glossectomy, 13, 15 inking, 30, 32
sample dictation, 38
serosal surface, 34
H Laryngectomy
Head and neck anterior aspect, 21
floor of the mouth, 13, 16, 17 inking, 21, 22
glossectomy, 13, 15 opened view, 23
laryngectomy (see Laryngectomy) opened view after fixation, 23, 24
salivary gland, 16 posterior aspect, 21, 22
thyroidectomy, 16, 18 sample dictation, 23, 25
tonsillectomy, 13–15 sections, 23–25
uvula, 13, 16 Lobectomy
Hepatectomy bronchial and vascular margins, 86
anterior view grossing tips, 83
inking, 44 lobe resection with palpable subpleural tumor, 85
segments in, 44 sample dictation, 83
total hepatectomy specimen, 44 Lumpectomy
grossing tips, 43 grossing, 9
posterior view inking, 9, 10
inking, 45 with localization wire, 9
segments in, 44 mapping, 9, 11
sample dictation, 43 margins of resection, 9
sectioning, 45 sample dictation, 9, 11
serial sections with tumor, 46 sections, 9, 10
Hilar invasion, 55, 58 survival outcomes, 5
Hysterectomy Lung
adnexa, 67 lobectomy, 83, 85, 86
anterior, 67, 68 pneumonectomy, 83–85
anterior and posterior, 67, 69 wedge resection, 83, 86
bivalved, 67, 69
endometrial carcinoma, 67, 72
with polyp, 67, 71 M
posterior, 67, 68 Mastectomy
radical hysterectomy, 67 grossing, 5, 8
sample dictation, 73, 74 inking of margins, 5, 6

Index 97

mapping, 8 biopsy, 5
margins, 5 grossing, 11, 12
modified radical mastectomy, 5 Skin ellipse, 1, 2
nipple-sparing mastectomy, 5 Skin excision
orientation, 5, 6 clock positions, 1
radical mastectomy, 5 ellipse shape, 1, 2
sample dictation, 8, 9 inking, 1, 3
sectioning, 5, 7 irregular, 1, 4
skin-sparing mastectomy, 5 margins, 1
slices, 5, 7 orientation, 1, 2
total simple mastectomy, 5 pigmented lesion, 1
Meckel’s diverticulum, 31 sample dictation, 1
Myometrium, 71, 73, 74 with scarred and pigmented lesions, 3
sectioning, 1, 4
Small bowel
N inking, 31
Nephrectomy Meckel’s diverticulum, 30
partial nephrectomy subserosal tumor resection, 31
orientation, 59 subserosal tumor sectioning, 31
sectioning, 59, 60 Splenectomy, 53
radical nephrectomy Splenic capsule, 53
bivalved surface, 55, 57 Submandibular glands, 16, 18
Hilar invasion, 55, 58 Supracervical hysterectomy, 67, 70, 73
margins, 55, 56
orientation, 55, 56
parallel sectioning, 55, 57 T
perpendicular sectioning, 55, 58 Thyroid nodules, 18, 21
polycystic kidney, 55, 58, 59 Thyroidectomy
sample dictation, 57, 58 inking, 18, 20
lobes and isthmus positions, 18, 19
sample dictation, 19, 21
O sectioning, 18, 20
Oophorectomy, 67 thyroid nodules, 18, 21
corpora lutea and albicantia, 77 Tonsillectomy
cystic ovary, 75 cerebriform appearance, 13, 14
cyst roll, 76 with papilloma, 13, 15
cystic teratoma, 76 sectioned tonsils, 13, 14
inner lining and papillary excrescences, 75 Tracheostomy, 21, 23
sample dictation, 74, 78 Transmetatarsal amputation, 94
sectioning, 77
Orchiectomy
bivalved testis, 63, 64 U
testis and spermatic cord margin, 63, 64 Uvulectomy, 13, 16
testis cut surface with tumor, 63, 65

V
P Vulvectomy, 67
Pancreaticoduodenectomy, see Whipple resection inking of margins, 78, 80
Parotid glands, 16 larger vulvectomy specimen, 78
Pneumonectomy sample dictation, 78, 81
left pneumonectomy, 84 specimen, 78, 80, 81
right pneumonectomy, 84
sections, 85
specimen, 83 W
Polycystic kidney, 55, 58, 59 Wedge resection, 83, 86
Polyp, 38–4071 Whipple resection
Polypectomy, 40 ampulla, 49
Purulent serosal exudate, 40 duodenum, 48
opened ducts, 49, 50
pancreas, 47, 48
S portion of the stomach, 47, 48
Salivary glands retroperitoneal margin, 48, 49
parotid glands, 16, 18, 19 sample dictation, 50, 52
submandibular glands, 16, 18 sections, 50
Salpingectomy, 74, 78, 79 slice, 50, 51
SEE-FIM protocol, 73, 78 submitting sections, 50, 51
Sentinel lymph nodes vascular groove, 48, 49